Implementation of distress screening in an oncology setting

Shared decision-making and disease management in advanced cancer and chronic kidney disease using patient-reported outcome dashboards

OBJECTIVES

To assess the use of a co-designed patient-reported outcome (PRO) clinical dashboard and estimate its impact on shared decision-making (SDM) and symptomatology in adults with advanced cancer or chronic kidney disease (CKD).

MATERIALS AND METHODS

We developed a clinical PRO dashboard within the Northwestern Medicine Patient-Reported Outcomes system, enhanced through co-design involving 20 diverse constituents. Using a single-group, pretest-posttest design, we evaluated the dashboard's use among patients with advanced cancer or CKD between June 2020 and January 2022. Eligible patients had a visit with a participating clinician, completed at least two dashboard-eligible visits, and consented to follow-up surveys. PROs were collected 72 h prior to visits, including measures for chronic condition management self-efficacy, health-related quality of life (PROMIS measures), and SDM (collaboRATE). Responses were integrated into the EHR dashboard and accessible to clinicians and patients.

RESULTS

We recruited 157 participants: 66 with advanced cancer and 91 with CKD. There were significant improvements in SDM from baseline, as assessed by collaboRATE scores. The proportion of participants reporting the highest level of SDM on every collaboRATE item increased by 15 percentage points from baseline to 3 months, and 17 points between baseline and 6-month follow-up. Additionally, there was a clinically meaningful decrease in anxiety levels over study period (T-score baseline: 53; 3-month: 52; 6-month: 50; P < .001), with a standardized response mean (SRM) of -0.38 at 6 months.

DISCUSSION

PRO clinical dashboards, developed and shared with patients, may enhance SDM and reduce anxiety among patients with advanced cancer and CKD.

A mixed methods evaluation of patient perspectives on the implementation of an electronic health record-integrated patient-reported symptom and needs monitoring program in cancer care

BACKGROUND

As cancer centers have increased focus on patient-centered, evidenced-based care, implementing efficient programs that facilitate effective patient-clinician communication remains critical. We implemented an electronic health record-integrated patient-reported symptom and needs monitoring program ('cPRO' for cancer patient-reported outcomes). To aid evaluation of cPRO implementation, we asked patients receiving care in one of three geographical regions of an academic healthcare system about their experiences.

METHODS

Using a sequential mixed-methods approach, we collected feedback in two waves. Wave 1 included virtual focus groups and interviews with patients who had completed cPRO. In Wave 2, we administered a structured survey to systematically examine Wave 1 themes. All participants had a diagnosed malignancy and received at least 2 invitations to complete cPRO. We used rapid and traditional qualitative methods to analyze Wave 1 data and focused on identifying facilitators and barriers to cPRO implementation. Wave 2 data were analyzed descriptively.

RESULTS

Participants (n = 180) were on average 62.9 years old; were majority female, White, non-Hispanic, and married; and represented various cancer types and phases of treatment. Wave 1 participants (n = 37) identified facilitators, including cPRO's perceived value and favorable usability, and barriers, including confusion about cPRO's purpose and various considerations for responding. High levels of clinician engagement with, and patient education on, cPRO were described as facilitators while low levels were described as barriers. Wave 2 (n = 143) data demonstrated high endorsement rates of cPRO's usability on domains such as navigability (91.6%), comprehensibility (98.7%), and relevance (82.4%). Wave 2 data also indicated low rates of understanding cPRO's purpose (56.7%), education from care teams about cPRO (22.5%), and discussing results of cPRO with care teams (16.3%).

CONCLUSIONS

While patients reported high value and ease of use when completing cPRO, they also reported areas of confusion, emphasizing the importance of patient education on the purpose and use of cPRO and clinician engagement to sustain participation. These results guided successful implementation changes and will inform future improvements.

Integrative Oncology Care of Symptoms of Anxiety and Depression in Adults With Cancer: SIO-ASCO Guideline Summary and Q&A

This SIO-ASCO guideline Q&A provides guidance on integrative oncology care of symptoms of anxiety and depression in adult patients with cancer

Implementation of Patient Reported Outcomes in Outpatient Palliative Care: From Paper to Computer

BACKGROUND

This quality improvement project aimed to transition completion of Edmonton Symptom Assessment System (ESAS) at our supportive care clinic from paper to electronic format.

MEASURES

Proportion of patients who completed electronic ESAS (eESAS).

INTERVENTION

Starting July 2018, patients could complete eESAS 24h before check-in (eESAS-before), eESAS after check-in (eESAS-after) or on paper (pESAS).

OUTCOMES

A total of 6631 cancer patients had 25,767 clinic visits between July 13, 2018 and November 5, 2021. The ESAS completion rate was 100%. eESAS uptake gradually increased over time, first reaching ≥75% eESAS completion in 5/2019 (eESAS-after 61.9%; eESAS-before 14.0%; pESAS 24.1%). We observed a sharp uptake in eESAS-before since adoption of telehealth during the pandemic (May 2020) and the ≥75% eESAS target was consistently achieved from November 2020 onwards (eESAS-after 0.6%; eESAS-before 76.7%; pESAS 22.7%). In an anonymous survey, we identified several modifiable barriers to implementing eESAS.

CONCLUSIONS

Transition to eESAS was a gradual process and was catalyzed by the pandemic.

Implementation and evaluation of an expanded electronic health record-integrated bilingual electronic symptom management program across a multi-site Comprehensive Cancer Center: The NU IMPACT protocol

BACKGROUND

People with cancer experience symptoms that adversely affect quality of life. Despite existing interventions and clinical guidelines, timely symptom management remains uneven in oncology care. We describe a study to implement and evaluate an electronic health record (EHR)-integrated symptom monitoring and management program in adult outpatient cancer care.

METHODS

Our cancer patient-reported outcomes (cPRO) symptom monitoring and management program is a customized EHR-integrated installation. We will implement cPRO across all Northwestern Memorial HealthCare (NMHC) hematology/oncology clinics. We will conduct a cluster randomized modified stepped-wedge trial to evaluate patient and clinician engagement with cPRO. Further, we will embed a patient-level randomized clinical trial to evaluate the impact of an additional enhanced care (EC; cPRO plus web-based symptom self-management intervention) relative to usual care (UC; cPRO alone). The project uses a Type 2 hybrid effectiveness-implementation approach. The intervention will be implemented across seven regional clusters within the healthcare system comprising 32 clinic sites. A 6-month prospective pre-implementation enrollment period will be followed by a post-implementation enrollment period, during which newly enrolled, consenting patients will be randomly assigned (1:1) to EC or UC. We will follow patients for 12 months post-enrollment. Patients randomized to EC will receive evidence-based symptom-management content on cancer-related concerns and approaches to enhance quality of life, using a web-based tool ("MyNM Care Corner"). This design allows for within- and between-site evaluation of implementation plus a group-based comparison to demonstrate effectiveness on patient-level outcomes.

DISCUSSION

The project has potential to guide implementation of future healthcare system-level cancer symptom management programs. http://ClinicalTrials.gov # NCT03988543.

Psychometrics of patient-reported bother from side effects of treatment single-items in industry-sponsored oncology trials

BACKGROUND

Improvements in cancer treatment have increased the number of cancer survivors, but also increased the long-term and late effects from cancer therapy. Patient reported "side effect bother" could be used to measure the burden of treatment, and the risk for negative outcomes such as dose reduction, treatment delay or discontinuation. The current study addresses the psychometric properties of a single item, determines what represents a "meaningful change", and evaluates the correlation to safety endpoints and functioning.

METHODS

Results from 5911 patients enrolled in 8 clinical trials representing 5 disease types in oncology and hematology who completed either the Functional Assessment of Cancer Therapy (FACT) GP5 item or a modified bother item (MBI) were assessed.

RESULTS

Patients ranged in age from 18 to 93 years, with all cancer stages represented and approximately equal numbers of males and females. Test-retest reliability was acceptable, as were convergent and known groups validity. The GP5 and MBI effectively demonstrated sensitivity to change over time and established meaningful thresholds.

CONCLUSIONS

The results indicate that these single-items are psychometrically sound, capable of distinguishing known groups, responsive to change and can identify meaningful change over time in terms of treatment-related symptoms. It extends the findings of recent scientific groups by providing analyses not included in prior studies, and further supports the FDA's recommendation to include a single item question in clinical trials.

Patient-Reported Outcome Dashboards Within the Electronic Health Record to Support Shared Decision-making: Protocol for Co-design and Clinical Evaluation With Patients With Advanced Cancer and Chronic Kidney Disease

BACKGROUND

Patient-reported outcomes-symptoms, treatment side effects, and health-related quality of life-are important to consider in chronic illness care. The increasing availability of health IT to collect patient-reported outcomes and integrate results within the electronic health record provides an unprecedented opportunity to support patients' symptom monitoring, shared decision-making, and effective use of the health care system.

OBJECTIVE

The objectives of this study are to co-design a dashboard that displays patient-reported outcomes along with other clinical data (eg, laboratory tests, medications, and appointments) within an electronic health record and conduct a longitudinal demonstration trial to evaluate whether the dashboard is associated with improved shared decision-making and disease management outcomes.

METHODS

Co-design teams comprising study investigators, patients with advanced cancer or chronic kidney disease, their care partners, and their clinicians will collaborate to develop the dashboard. Investigators will work with clinic staff to implement the co-designed dashboard for clinical testing during a demonstration trial. The primary outcome of the demonstration trial is whether the quality of shared decision-making increases from baseline to the 3-month follow-up. Secondary outcomes include longitudinal changes in satisfaction with care, self-efficacy in managing treatments and symptoms, health-related quality of life, and use of costly and potentially avoidable health care services. Implementation outcomes (ie, fidelity, appropriateness, acceptability, feasibility, reach, adoption, and sustainability) during the co-design process and demonstration trial will also be collected and summarized.

RESULTS

The dashboard co-design process was completed in May 2020, and data collection for the demonstration trial is anticipated to be completed by the end of July 2022. The results will be disseminated in at least one manuscript per study objective.

CONCLUSIONS

This protocol combines stakeholder engagement, health care coproduction frameworks, and health IT to develop a clinically feasible model of person-centered care delivery. The results will inform our current understanding of how best to integrate patient-reported outcome measures into clinical workflows to improve outcomes and reduce the burden of chronic disease on patients and health care systems.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/38461.

The prognostic impact of depression or depressive symptoms on patients with head and neck cancer: A systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis sought to assess the extent to which pretreatment depression or depressive symptoms are related to prognosis in patients with head and neck cancer (HNC).

METHODS

Medline, EMbase, Scopus, and The Cochrane Library databases were searched. A meta-analysis was done to generate a forest plot and pooled hazard ratio (HR) with 95% CI for overall survival (OS). RevMan 5.3 and Meta Essentials were used for statistical analysis.

RESULTS

Based on seven studies involving 1743 patients, the results showed that HNC patients with pretreatment depression or depressive symptoms had worse OS than patients without depression or depressive symptoms, with an HR of 1.33, 95% CI 1.16-1.52, p = <0.0001. There is heterogeneity in the pooled summary effect (I²  = 80%, p < 0.0001).

CONCLUSIONS

Pretreatment depression or depressive symptoms may indicate worse OS in patients with HNC. The pooled analysis demonstrated a statistically significant effect. These results were limited by mild heterogeneity.

Optimizing Health Information Technologies for Symptom Management in Cancer Patients and Survivors: Usability Evaluation

Background

Unmanaged cancer symptoms and treatment-related side effects can compromise long-term clinical outcomes and health-related quality of life. Health information technologies such as web-based platforms offer the possibility to supplement existing care and optimize symptom management.

Objective

This paper describes the development and usability of a web-based symptom management platform for cancer patients and survivors that will be implemented within a large health system.

Methods

A web-based symptom management platform was designed and evaluated via one-on-one usability testing sessions. The System Usability Scale (SUS), After Scenario Questionnaire (ASQ), and qualitative analysis of semistructured interviews were used to assess program usability.

Results

Ten cancer survivors and five cancer center staff members participated in usability testing sessions. The mean score on the SUS was 86.6 (SD 14.0), indicating above average usability. The mean score on the ASQ was 2.5 (SD 2.1), indicating relatively high satisfaction with the usability of the program. Qualitative analyses identified valued features of the program and recommendations for further improvements.

Conclusions

Cancer survivors and oncology care providers reported high levels of acceptability and usability in the initial development of a web-based symptom management platform for cancer survivors. Future work will test the effectiveness of this web-based platform.

Leveraging Patient Reported Outcomes Measurement via the Electronic Health Record to Connect Patients with Cancer to Smoking Cessation Treatment

Tobacco use negatively impacts cancer treatment outcomes, yet too few providers actively support their patients in quitting. Barriers to consistently addressing tobacco use and referring to treatment include time constraints and lack of knowledge surrounding treatment options. Patient Reported Outcomes (PRO) measurement is best practice in cancer care and has potential to help address these barriers to tobacco cessation treatment. This descriptive program evaluation study reports preliminary results following implementation of a novel automated PRO tobacco use screener and referral system via the electronic health record (EHR) patient portal (MyChart) that was developed and implemented as a part of a population-based tobacco treatment program at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Between 25 June 2019 and 6 April 2020, 4589 unique patients completed the screener and 164 (3.6%) unique patients screened positive for recent (past month) cigarette smoking. All patients who screened positive were automatically referred to a smoking cessation treatment program integrated within the Lurie Cancer Center, and 71 (49.7%) patients engaged in treatment, as defined by completing at least one behavioral counseling session. Preliminary results indicate that the PRO/MyChart system may improve smoker identification and increase offering of treatment and, despite the "cold call" following a positive screen, may result in a treatment engagement rate that is higher than rates of treatment engagement previously documented in oncology settings. Longer term evaluation with formal statistical testing is needed before drawing conclusions regarding effectiveness, but PRO measurement via the EHR patient portal may serve a potentially important role in a multi-component approach to reaching and engaging cancer patients in comprehensive tobacco cessation treatment.

Establishing a common metric for self-reported anxiety in patients with prostate cancer: Linking the Memorial Anxiety Scale for Prostate Cancer with PROMIS Anxiety

BACKGROUND

Anxiety is a common patient concern and clinical endpoint in prostate cancer outcomes research. It is measured using different self-report instruments that are not directly comparable, thereby making clinical trials, clinical performance measurement, and comparative effectiveness research challenging when anxiety is the outcome of interest. The objective of the current study was to enable a common reporting metric of anxiety so that scores on commonly used anxiety measures could be converted into Patient-Reported Outcomes Measurement Information System (PROMIS) scores for ease of application, interpretation, and comparability.

METHODS

Using an internet health panel, a total of 806 men with clinically localized prostate cancer completed items from the National Institutes of Health PROMIS Anxiety Short Form (version 7a) and the 18-item Memorial Anxiety Scale for Prostate Cancer (MAX-PC). A common metric was created using analyses based on item response theory, producing score crosswalk tables. The linking relationships were evaluated by resampling small subsets and estimating confidence intervals for the differences between the observed and linked PROMIS scores.

RESULTS

Results of factor analysis and item response theory model fit supported the hypothesis that both scales measure essentially the same concept. Therefore, crosswalk tables appear to be justified and increasingly robust with increasing sample sizes.

CONCLUSIONS

MAX-PC Anxiety results can be expressed on the PROMIS Anxiety metric for the purposes of clinical performance measurement, clinical trial outcomes, comparative effectiveness research, and other efforts to compare anxiety results across studies that use any one of these measures.

Provider perspectives on the integration of patient-reported outcomes in an electronic health record

OBJECTIVE

Integrating patient-reported outcomes (PROs) into electronic health records (EHRs) can improve patient-provider communication and delivery of care. However, new system implementation in health-care institutions is often accompanied by a change in clinical workflow and organizational culture. This study examines how well an EHR-integrated PRO system fits clinical workflows and individual needs of different provider groups within 2 clinics.

MATERIALS AND METHODS

Northwestern Medicine developed and implemented an EHR-integrated PRO system within the orthopedics and oncology departments. We conducted interviews with 11 providers who had interacted with the system. Through thematic analysis, we synthesized themes regarding provider perspectives on clinical workflow, individual needs, and system features.

RESULTS

Our findings show that EHR-integrated PROs facilitate targeted conversation with patients and automated triage for psychosocial care. However, physicians, psychosocial providers, and medical assistants faced different challenges in their use of the PRO system. Barriers mainly stemmed from a lack of actionable data, workflow disruption, technical issues, and a lack of incentives.

DISCUSSION

This study sheds light on the ecosystem around EHR-integrated PRO systems (such as user needs and organizational factors). We present recommendations to address challenges facing PRO implementation, such as optimizing data collection and auto-referral processes, improving data visualizations, designing effective educational materials, and prioritizing the primary user group.

CONCLUSION

PRO integration into routine care can be beneficial but also require effective technology design and workflow configuration to reach full potential use. This study provides insights into how patient-generated health data can be better integrated into clinical practice and care delivery processes.

Barriers and facilitators to implementing the commission on cancer's distress screening program standard

OBJECTIVE

Many cancer centers struggle to implement standardized distress screening despite the American College of Surgeons' Commission on Cancer 2012 mandate for a distress screening program standard of care by 2015. This paper presents outcomes for the first cohort of participants (n = 36) of a Screening for Psychosocial Distress Program (SPDP), a 2-year training program designed to assist clinicians in implementing routine distress screening as mandated by the American College of Surgeons Commission on Cancer. Specifically, participants' success with distress screening implementation, institutional barriers and facilitators to implementation, and the role of the SPDP are described.

METHOD

This research followed a longitudinal pre- and posttest mixed methods design. An investigator-developed questionnaire collected qualitative (distress screening goals, institutional barriers and facilitators, facilitators associated with participation in the SPDP) and quantitative (level of goal achievement) data at 6, 12, and 24 months of participation in the SPDP. Conventional content analysis was applied to qualitative data. Mixed methods data analysis in Dedoose evaluated (1) types and number of distress screening goals, barriers, and facilitators, and (2) goal achievement at 6, 12, and 24 months of participation.ResultNinety-five percent of distress screening implementation goals were completed after 2 years of participation. Most common institutional barriers to distress screening implementation were "lack of staff," "competing demands," and "staff turn-over." Most common institutional facilitators were "buy-in," "institutional support," and "recognition of participants' expertise." The number of reported facilitators associated with SPDP participation was higher than the number associated with any institutional factor, and increased over time of participation.Significance of resultsParticipating in training programs to implement distress screening may facilitate successful achievement of the Commission on Cancer's distress screening standard, and benefits seem to increase with time of participation. Training programs are needed to promote facilitators and overcome barriers to distress screening.

Validity and usefulness of a single-item measure of patient-reported bother from side effects of cancer therapy

BACKGROUND

The improving efficacy of cancer treatment has resulted in an increasing array of treatment-related symptoms and associated burdens imposed on individuals undergoing aggressive treatment of their disease. Often, clinical trials compare therapies that have different types, and severities, of adverse effects. Whether rated by clinicians or patients themselves, it can be difficult to know which side effect profile is more disruptive or bothersome to patients. A simple summary index of bother can help to adjudicate the variability in adverse effects across treatments being compared with each other.

METHODS

Across 4 studies, a total of 5765 patients enrolled in cooperative group studies and industry-sponsored clinical trials were the subjects of the current study. Patients were diagnosed with a range of primary cancer sites, including bladder, brain, breast, colon/rectum, head/neck, hepatobiliary, kidney, lung, ovary, pancreas, and prostate as well as leukemia and lymphoma. All patients were administered the Functional Assessment of Cancer Therapy-General version (FACT-G). The single item "I am bothered by side effects of treatment" (GP5), rated on a 5-point Likert scale, is part of the FACT-G. To determine its validity as a useful summary measure from the patient perspective, it was correlated with individual and aggregated clinician-rated adverse events and patient reports of their general ability to enjoy life.

RESULTS

Analyses of pharmaceutical trials demonstrated that mean GP5 scores ("I am bothered by side effects of treatment") significantly differed by maximum adverse event grade (P<.001) in all trials, with a clear trend toward increasing GP5 scores with level of increasing adverse event grade. Effect sizes ranged from 0.13 to 0.46. Analyses of cooperative group trials demonstrated a significant correlation between GP5 and item GF3 ("I am able to enjoy life") in the predicted direction.

CONCLUSIONS

The single FACT-G item "I am bothered by side effects of treatment" is significantly associated with clinician-reported adverse events and with patients' ability to enjoy their lives. It has promise as an overall summary measure of the burden of a given set of treatment toxicities compared with another. Future research can identify the contribution of individual side effects compared with one another in terms of how each may contribute to overall bother. Cancer 2018;124:991-7. © 2017 American Cancer Society.

Implementation of the Edmonton Symptom Assessment System for Symptom Distress Screening at a Community Cancer Center: A Pilot Program

A better understanding of how the Edmonton Symptom Assessment System (ESAS) can be used for distress screening may facilitate its use to improve patient care. In 2015, the General Medical Oncology Outpatient Clinic at Lyndon B. Johnson Hospital implemented a pilot project with ESAS for distress screening. The impact of ESAS screening on access to psychosocial care before and after program implementation is reported here.

Background.

Distress screening is mandated by the American College of Surgeons Commission on Cancer; however, there is limited literature on its impact in actual practice. We examined the impact of a pilot distress screening program on access to psychosocial care.

Methods.

Edmonton Symptom Assessment System (ESAS) screening was routinely conducted at our community‐based medical oncology program. Patients who screened positive for severe distress were sent to a social worker for triage and referred to the appropriate services if indicated. We compared the proportion of patients who had ESAS completed, the proportion of patients who screened positive, and the number of patients who had social work assessment and palliative care consultation over the preimplementation (September 2015), training (October/November 2015), and postimplementation (December 2015) periods.

Results.

A total of 379, 328, and 465 cancer patients were included in the preimplementation, training, and postimplementation periods, respectively. The proportion of patients who completed ESAS increased over time (83% vs. 91% vs. 96%). Among the patients who had completed ESAS, between 11% and 13% were positive for severe distress, which remained stable over the three periods. We observed a significant increase in social work referrals for psychosocial assessment (21% vs. 71% vs. 79%). There was also a trend towards an increased number of palliative care referrals (12% vs. 20% vs. 28%).

Conclusion.

Our community‐based cancer center implemented distress screening rapidly in a resource‐limited setting, with a notable increase in symptom documentation and psychosocial referral.

Implications for Practice.

The American College of Surgeons Commission on Cancer mandates distress screening; however, there is limited literature on how this process should be implemented and its impact on clinical practice. We used the Edmonton Symptom Assessment System for routine symptom distress screening in a community‐based medical oncology program that provides care for an underserved population. Comparing before and after program implementation, we found an increase in the number of documentations of symptom burden and an increase in psychosocial referrals. Findings from this study may inform the implementation of routine symptom distress screening in cancer patients.