Effectiveness and cost-effectiveness of a digital health intervention to support patients with colorectal cancer prepare for and recover from surgery: study protocol of the RecoverEsupport randomised controlled trial

INTRODUCTION

Surgery is the most common treatment for colorectal cancer (CRC) and can cause relative long average length of stay (LOS) and high risks of unplanned readmissions and complications. Enhanced Recovery After Surgery (ERAS) pathways can reduce the LOS and postsurgical complications. Digital health interventions provide a flexible and low-cost way of supporting patients to achieve this. This protocol describes a trial aiming to evaluate the effectiveness and cost-effectiveness of the RecoverEsupport digital health intervention in decreasing the hospital LOS in patients undergoing CRC surgery.

METHODS AND ANALYSIS

The two-arm randomised controlled trial will assess the effectiveness and cost-effectiveness of the RecoverEsupport digital health intervention compared with usual care (control) in patients with CRC. The intervention consists of a website and a series of automatic prompts and alerts to support patients to adhere to the patient-led ERAS recommendations. The primary trial outcome is the length of hospital stay. Secondary outcomes include days alive and out of hospital; emergency department presentations; quality of life; patient knowledge and behaviours related to the ERAS recommendations; health service utilisation; and intervention acceptability and use.

ETHICS AND DISSEMINATION

The trial has been approved by the Hunter New England Research Ethics Committee (2019/ETH00869) and the University of Newcastle Ethics Committee (H-2015-0364). Trial findings will be disseminated via peer-reviewed publications and conference presentations. If the intervention is effective, the research team will facilitate its adoption within the Local Health District for widespread adaptation and implementation.

TRIAL REGISTRATION NUMBER

ACTRN12621001533886.

Gynecologic Survivorship Tool: Development, Implementation, and Symptom Outcomes

PURPOSE

To describe the development and implementation of a new digital health clinical tool (Gynecologic Survivorship Tool [GST]) for symptom management of women surgically treated for gynecologic cancer; to assess its feasibility; and to conduct a retrospective review of the data.

MATERIALS AND METHODS

The GST was developed on the basis of a comprehensive review of the literature, multidisciplinary expert opinion, and feedback from women with a history of gynecologic cancer. It is composed of 17 questions addressing six main categories-gynecologic health (abnormal bleeding/pain), lymphedema, vaginal/vulvar dryness, sexual health, menopause (hot flushes/sleep difficulties), and bowel/urinary issues. An electronic version using the Memorial Sloan Kettering Cancer Center Engage platform was piloted in two clinics for patients with endometrial or cervical cancer. Health information was generated into clinical summaries and identified concerns for actionable response. Associations of symptom and survey time point were assessed by longitudinal models using generalized estimating equations.

RESULTS

From January 1, 2019, to February 29, 2020, 3,357 GST assessments were assigned to 1,405 patients, with a 71% completion rate (90% within 5 minutes). Sixty-eight percent were performed at home via a patient portal, 32% at follow-ups using a clinic iPad. The most common symptoms were bowel problems, swelling/fluid, pain during examination, vaginal or vulvar dryness, and vaginal bleeding. Implementation challenges included improving patient compliance and ensuring that reports were reviewed by all clinical teams. We developed screening e-mails detailing patients whose assessments were due, planned training sessions for multidisciplinary teams, and incorporated feedback on methods for reviewing symptoms reports.

CONCLUSION

The GST demonstrated feasibility, a high completion rate, and minimal time commitment. It was an effective electronic reporting mechanism for patients, enabling the medical team to develop specific strategies for alleviating bothersome symptoms during follow-up.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Role of eHealth in Optimizing Preventive Care in the Primary Care Setting

Modifiable health risk behaviors such as smoking, overweight and obesity, risky alcohol consumption, physical inactivity, and poor nutrition contribute to a substantial proportion of the world’s morbidity and mortality burden. General practitioners (GPs) play a key role in identifying and managing modifiable health risk behaviors. However, these are often underdetected and undermanaged in the primary care setting. We describe the potential of eHealth to help patients and GPs to overcome some of the barriers to managing health risk behaviors. In particular, we discuss (1) the role of eHealth in facilitating routine collection of patient-reported data on lifestyle risk factors, and (2) the role of eHealth in improving clinical management of identified risk factors through provision of tailored feedback, point-of-care reminders, tailored educational materials, and referral to online self-management programs. Strategies to harness the capacity of the eHealth medium, including the use of dynamic features and tailoring to help end users engage with, understand, and apply information need to be considered and maximized. Finally, the potential challenges in implementing eHealth solutions in the primary care setting are discussed. In conclusion, there is significant potential for innovative eHealth solutions to make a contribution to improving preventive care in the primary care setting. However, attention to issues such as data security and designing eHealth interfaces that maximize engagement from end users will be important to moving this field forward.

Development and usability testing of a web-based cancer symptom and quality-of-life support intervention

The feasibility and acceptability of computerized screening and patient-reported outcome measures have been demonstrated in the literature. However, patient-centered management of health information entails two challenges: gathering and presenting data using "patient-tailored" methods and supporting "patient-control" of health information. The design and development of many symptom and quality-of-life information systems have not included opportunities for systematically collecting and analyzing user input. As part of a larger clinical trial, the Electronic Self-Report Assessment for Cancer-II project, participatory design approaches were used to build and test new features and interfaces for patient/caregiver users. The research questions centered on patient/caregiver preferences with regard to the following: (a) content, (b) user interface needs, (c) patient-oriented summary, and (d) patient-controlled sharing of information with family, caregivers, and clinicians. Mixed methods were used with an emphasis on qualitative approaches; focus groups and individual usability tests were the primary research methods. Focus group data were content analyzed, while individual usability sessions were assessed with both qualitative and quantitative methods. We identified 12 key patient/caregiver preferences through focus groups with 6 participants. We implemented seven of these preferences during the iterative design process. We deferred development for some of the preferences due to resource constraints. During individual usability testing (n = 8), we were able to identify 65 usability issues ranging from minor user confusion to critical errors that blocked task completion. The participatory development model that we used led to features and design revisions that were patient centered. We are currently evaluating new approaches for the application interface and for future research pathways. We encourage other researchers to adopt user-centered design approaches when building patient-centered technologies.

Do we get it right? Radiation oncology outpatients' perceptions of the patient centredness of life expectancy disclosure

OBJECTIVE

A patient-centred approach to discussing life expectancy with cancer patients is recommended in Western countries. However, this approach to eliciting and meeting patient preferences can be challenging for clinicians. The aims of this study were the following: (i) to examine cancer patients' preferences for life expectancy disclosure; and (ii) to explore agreement between cancer patients' preferences for, and perceived experiences of, life expectancy disclosure.

METHODS

Cancer patients undergoing radiotherapy treatment in metropolitan Australia completed a cross-sectional touchscreen computer survey including optional questions about their life expectancy disclosure preferences and experiences.

RESULTS

Of the 208 respondents, 178 (86%) indicated that they would prefer their clinician to ask them before discussing life expectancy, and 30 (14%) indicated that they would prefer others (i.e. clinicians, family) to decide whether they were given life expectancy information. Of the 175 respondents who were classified as having a self- determined or other-determined disclosure experience, 105 (60%) reported an experience of life expectancy disclosure that was in accordance with their preferences. Cohen's κ was -0.04 (95% CI, -0.17, 0.08), indicating very poor agreement between patients' preferences for and perceived experiences of life expectancy disclosure (p = 0.74).

CONCLUSIONS

In light of patient-centred prognosis disclosure guidelines, our findings of a majority preference for, and experience of, a self-determined approach to life expectancy disclosure amongst radiation oncology patients are encouraging. However, poor agreement between preferences and experiences highlights that additional effort from clinicians is required in order to achieve a truly patient-centred approach to life expectancy disclosure.

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

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

Cancer patients' willingness to answer survey questions about life expectancy

Purpose

This study aimed to determine the proportion and characteristics of radiation oncology outpatients who were willing to answer questions about their life expectancy.

Methods

A cross-sectional patient self-report survey was conducted using touch screen computers in Australian radiation oncology treatment centers. The primary outcome was the respondent’s willingness to complete a survey subsection about life expectancy. Demographic and disease characteristics were also collected, and level of anxiety and depression was assessed using the Hospital Anxiety and Depression Scale.

Results

Of the 469 oncology outpatients who completed the survey, 327 (70 %; 95 % CI, 65 %, 74 %) indicated that they were willing to answer questions about life expectancy. Being female (p < 0.001), older (p < 0.05), born in Asia (p < 0.05), and being diagnosed with cancer types other than breast and prostate cancer (p < 0.01) were associated with lower odds of answering life expectancy questions.

Conclusions

The opportunity to opt-out of survey questions about sensitive issues such as life expectancy is a feasible method for accessing important information about patient preferences while minimizing burden. Further research may be needed to improve acceptability of life expectancy research to some patient groups.

Assessing smoking status in disadvantaged populations: is computer administered self report an accurate and acceptable measure?

Background

Self report of smoking status is potentially unreliable in certain situations and in high-risk populations. This study aimed to determine the accuracy and acceptability of computer administered self-report of smoking status among a low socioeconomic (SES) population.

Methods

Clients attending a community service organisation for welfare support were invited to complete a cross-sectional touch screen computer health survey. Following survey completion, participants were invited to provide a breath sample to measure exposure to tobacco smoke in expired air. Sensitivity, specificity, positive predictive value and negative predictive value were calculated.

Results

Three hundred and eighty three participants completed the health survey, and 330 (86%) provided a breath sample. Of participants included in the validation analysis, 59% reported being a daily or occasional smoker. Sensitivity was 94.4% and specificity 92.8%. The positive and negative predictive values were 94.9% and 92.0% respectively. The majority of participants reported that the touch screen survey was both enjoyable (79%) and easy (88%) to complete.

Conclusions

Computer administered self report is both acceptable and accurate as a method of assessing smoking status among low SES smokers in a community setting. Routine collection of health information using touch-screen computer has the potential to identify smokers and increase provision of support and referral in the community setting.

Patient or treatment centre? Where are efforts invested to improve cancer patients' psychosocial outcomes?

The psychosocial outcomes of cancer patients may be influenced by individual-level, social and treatment centre predictors. This paper aimed to examine the extent to which individual, social and treatment centre variables have been examined as predictors or targets of intervention for psychosocial outcomes of cancer patients. Medline was searched to find studies in which the psychological outcomes of cancer patient were primary variables. Papers published in English between 1999 and 2009 that reported primary data relevant to psychosocial outcomes for cancer patients were included, with 20% randomly selected for further coding. Descriptive studies were coded for inclusion of individual, social or treatment centre variables. Intervention studies were coded to determine if the unit of intervention was the individual patient, social unit or treatment centre. After random sampling, 412 publications meeting the inclusion criteria were identified, 169 were descriptive and 243 interventions. Of the descriptive papers 95.0% included individual predictors, and 5.0% social predictors. None of the descriptive papers examined treatment centre variables as predictors of psychosocial outcomes. Similarly, none of the interventions evaluated the effectiveness of treatment centre interventions for improving psychosocial outcomes. Potential reasons for the overwhelming dominance of individual predictors and individual-focused interventions in psychosocial literature are discussed.

The next generation of the supportive care needs survey: a brief screening tool for administration in the clinical oncology setting

OBJECTIVE

The short form of the Supportive Care Needs Survey (SCNS-SF34) is a 34-item instrument for assessing the perceived needs of people diagnosed with cancer. This research is aimed at developing a brief screening tool for administration to patients in the clinical setting, by identifying the minimum number and optimal combination of item(s) to measure each of the SCNS-SF34 domains with high sensitivity and specificity.

METHODS

Secondary analyses were undertaken on data from 1458 patients at 12 major public cancer treatment centres in Australia; with a random sample of 67% (n = 977) of the patient records selected as the developmental sample for developing the screening tool, while the remaining 33% (n = 481) constituted the validation sample on which analyses were repeated. Five criteria were applied to identify the optimum subset of items for the screening tool. Where statistical results were very similar across candidate item/s, items deemed more clinically important were chosen.

RESULTS

Nine items were identified, which can be efficiently and reliably used as a brief screening tool (SCNS-ST9). An overall comparison of the results on the SCNS-ST9 with the original SCNS-SF34 indicates that only 11% of people reporting at least one moderate/high need on any SCNS-SF34 domain were missed as having a moderate/high need on the SCNS-ST9.

CONCLUSIONS

Our very brief screening tool can be implemented in a clinical setting to reliably screen for unmet needs among cancer patients, with considerable savings in time and expense, increasing its potential for wide-scale adoption in clinical settings.

Using information technology to reduce asthma disparities in underserved populations: a pilot study

BACKGROUND

Low health literacy has been identified as an independent predictor of poor asthma control. The Institute of Medicine considers the role of information technology (IT) as critical in providing "safe, effective, patient centered, timely, efficient, and equitable" care with the potential to reduce health disparities in underserved populations. The aim of this study was to design and evaluate an interactive computer-based questionnaire to assess asthma symptoms in children of parents with limited health literacy and/or limited English proficiency.

METHODS

Volunteer caregivers attending a mobile asthma clinic were randomly assigned to complete the electronic or the paper-and-pencil version of an asthma screening questionnaire (ASQ) in their language of choice (English or Spanish). In the electronic version, a tablet computer was used to present the ASQ questions as video clips and to collect information through the touchscreen. Participants also completed a demographic questionnaire, a brief health literacy questionnaire, and a system usability and satisfaction questionnaire. Reliability of the paper and electronic self-assessments was evaluated by comparing each participant's answers to information they provided during a nurse-guided structured interview (gold standard).

RESULTS

A total of 48 parents participated in the study, 26 completed the electronic ASQ and 21 the paper-and-pencil form. Thirty-five percent of the children had well-controlled asthma (n = 17). Most participants were Spanish speaking (67%) Hispanic (n = 44) mothers (n = 43) with a median age of 32 years. More than half had ≤8 years of education (n = 25) and earned <$20,000 per year (n = 27). The median health literacy score was 32 (range 0-36). The correlation between health literacy scores and years of education was significant (ρ = .47, p < .01). Concordance between the electronic ASQ and the nurse interview was significantly higher than concordance between the paper ASQ and the nurse interview (68% versus 54%; p < .01). All parents who completed the electronic questionnaire reported being satisfied; 96% felt comfortable using it, and found it simple to use.

CONCLUSIONS

By facilitating the assessment of asthma symptoms at manageable cost, interactive information technology tools may help reduce barriers to access due to inadequate levels of English proficiency and health literacy.

The validity and reliability of an interactive computer tobacco and alcohol use survey in general practice

BACKGROUND

Uncertainty regarding the accuracy of the computer as a data collection or patient screening tool persists. Previous research evaluating the validity of computer health surveys have tended to compare those responses to that of paper survey or clinical interview (as the gold standard). This approach is limited as it assumes that the paper version of the self-report survey is valid and an appropriate gold standard.

OBJECTIVES

First, to compare the accuracy of computer and paper methods of assessing self-reported smoking and alcohol use in general practice with biochemical measures as gold standard. Second, to compare the test re-test reliability of computer administration, paper administration and mixed methods of assessing self-reported smoking status and alcohol use in general practice.

METHODS

A randomised cross-over design was used. Consenting patients were randomly assigned to one of four groups; Group 1. C-C : completing a computer survey at the time of that consultation (Time 1) and a computer survey 4-7 days later (Time 2); Group 2. C-P: completing a computer survey at Time 1 and a paper survey at Time 2; Group 3. P-C: completing a paper survey at Time 1 and a computer survey at Time 2; and Group 4. P-P: completing a paper survey at Time 1 and 2. At Time 1 all participants also completed biochemical measures to validate self-reported smoking status (expired air carbon monoxide breath test) and alcohol consumption (ethyl alcohol urine assay).

RESULTS

Of the 618 who were eligible, 575 (93%) consented to completing the Time 1 surveys. Of these, 71% (N=411) completed Time 2 surveys. Compared to CO, the computer smoking self-report survey demonstrated 91% sensitivity, 94% specificity, 75% positive predictive value (PPV) and 98% negative predictive value (NPV). The equivalent paper survey demonstrated 86% sensitivity, 95% specificity, 80% PPV, and 96% NPV. Compared to urine assay, the computer alcohol use self-report survey demonstrated 92% sensitivity, 50% specificity, 10% PPV and 99% NPV. The equivalent paper survey demonstrated 75% sensitivity, 57% specificity, 6% PPV, and 98% NPV. Level of agreement of smoking self-reports at Time 1 and Time 2 revealed kappa coefficients ranging from 0.95 to 0.98 in each group and hazardous alcohol use self-reports at Time 1 and Time 2 revealed kappa coefficients ranging from 0.90 to 0.96 in each group.

CONCLUSION

The collection of self-reported health risk information is equally accurate and reliable using computer interface in the general practice setting as traditional paper survey. Computer survey appears highly reliable and accurate for the measurement of smoking status. Further research is needed to confirm the adequacy of the quantity/frequency measure in detecting those who drink alcohol. Interactive computer administered health surveys offer a number of advantages to researchers and clinicians and further research is warranted.

Acceptability of an Electronic Self-Report Assessment Program for patients with cancer

Eliciting symptom and quality of life information from patients is an important component of medical and nursing care processes. Traditionally, this information has been collected with paper and pencil. However, this approach presents several barriers, including delays in receiving information, difficulty in integrating responses with electronic records, and the time required to manually score questionnaires for measurement purposes. One solution that addresses many of these barriers is the adoption of computerized screening for symptom and quality-of-life information. This research explored the acceptability of asking symptom and quality-of-life questions using the Electronic Self Report Assessment-Cancer program on wireless laptops equipped with touch-screen format. Acceptability data were explored with respect to whether any differences may be attributed to demographics and symptom and quality-of-life levels, such as depression and cognitive and emotional functioning. This evaluation used descriptive and univariate statistics to examine data from 342 participants from the ongoing ESRA-C randomized clinical trial. Research participants for the ESRA-C study were recruited from the Seattle Cancer Care Alliance, a consortium among the University of Washington Medical Center, Fred Hutchinson Cancer Research Center, and Children's Hospital and Regional Medical Center in Seattle, WA. The sample consisted of 342 adult participants who completed both baseline and follow-up survey sessions. Medical oncology represented the largest recruitment group (45.3%), followed by stem cell transplant (34.5%) and radiation oncology (20.2%). The primary finding was that patients were generally able to use ESRA-C quickly and without difficulty in a real-world clinical setting and that they were overall quite satisfied with the ESRA-C program. Significant differences were found in several acceptability areas with respect to demographics and quality of life measures such as age, sex, and severe distress. This analysis confirms that the ESRA-C application for collecting symptom and quality of life information is easy for patients to use and acceptable across a range of user characteristics. We intend to build on our work by using the survey platform in other modalities while ensuring that the patient's preferences are considered at all times.

Quality of life assessment in women with breast cancer: benefits, acceptability and utilization

In 2006, breast cancer was the third leading cause of death in American women; however, more women survive breast cancer than any other type of cancer. As the disease progresses, it is important to know how one's health-related quality of life (QOL) is affected for those who receive treatment, those who survive, and those who remain disease-free. The purpose of this study was to summarize the benefits, challenges, and barriers of QOL measurement for female breast cancer patients. A PubMed literature search was conducted using the terms "quality of life" and "breast cancer." The search was then refined with terms related to QOL assessment instruments. The research team reviewed over 100 of the 2,090 articles identified. From the results, a detailed outline of QOL instruments is presented, and the effectiveness of QOL instruments is discussed. In the current literature review, both generic and breast cancer specific QOL instruments, examining computerized and paper-and-pencil versions, are explained as well as the advantages, acceptability, and problems of these assessments. Potential barriers to implementation are also discussed. The implementation of QOL assessment tools in breast cancer clinical practice is discussed, with evidence detailing how such tools would benefit patients.

Measuring social difficulties in routine patient-centred assessment: a Rasch analysis of the social difficulties inventory

BACKGROUND

Social difficulties may add to the psychological burden experienced by cancer patients. Therefore identifying social difficulties in routine oncology practice may help prevent or alleviate distress. The Social Difficulties Inventory (SDI) is a short questionnaire developed for assessing social difficulties in cancer patients. Although well-validated, not enough is known about the clinical meaning and utility of the instrument or whether the items can be meaningfully summed to form a summary index of "Social Distress".

PURPOSE

To determine, using Rasch analysis, whether the SDI could be used as a summary index of social distress specifically examining three fundamental criteria: item fit, unidimensionality and item invariance.

METHODS

The Partial Credit Model was applied to a heterogeneous sample of cancer patients (n = 609) who had completed the SDI.

RESULTS

Five items were identified as misfitting (infit mean square > or = 1.3 and standardised t-statistic > or = 2) and excluded from the subsequent analysis. The remaining items formed a unidimensional interval scale with no additional factors identified in a principal components analysis of the residuals. No differential item functioning was observed for age, gender, diagnosis, extent of disease or social deprivation. The 16-item SDI can be summed to produce an overall index of social distress, facilitating routine identification of social difficulties. Subsequent work is needed to evaluate whether the instrument is able to identify patients with high levels of social distress requiring intervention.

The impact of literacy on health-related quality of life measurement and outcomes in cancer outpatients

BACKGROUND

Limited evidence exists regarding the relationship between literacy and health-related quality of life (HRQL). Research is needed to develop measurement techniques for low literacy populations and to evaluate potential literacy-related measurement bias.

METHODS

A Talking Touchscreen (TT) was developed for an HRQL study. Low (n = 214) and high literacy (n = 201) adult cancer outpatients participated, 70% of whom were from racial/ethnic minorities. Patients completed three questionnaires by TT: FACT-G (cancer-specific), SF-36 (generic health status), and a standard gamble utility questionnaire. Measurement bias was evaluated using item response theory (IRT). Effects of literacy on HRQL were evaluated using regression models.

RESULTS

Most (97%) patients rated the TT easy to use. In IRT analysis, 6/27 FACT-G and 12/31 SF-36 items demonstrated literacy bias; this was relatively balanced (10 items 'biased against' low literacy; 8 'biased against' high literacy). Mean literacy group differences were statistically and clinically non-significant for 9/14 HRQL outcomes. Adjustment for bias and/or covariates eliminated most remaining differences.

CONCLUSIONS

The TT is valid and useful for HRQL assessment in low literacy populations. There appears to be no systematic literacy bias in reporting HRQL, and low literacy is not an independent risk factor for poorer HRQL.

Patient‐driven computers in primary care: their use and feasibility

Purpose

The purpose of this research is to explore the feasibility of using patient‐driven, hand‐held computers in primary care settings, in order to address the apparent failure to implement prevention initiatives into the routine delivery of health care services.

Design/methodology/approach

During an eight‐day period, patients of an English primary care practice who were at least 16 years of age were asked to complete a health‐related survey using a hand‐held computer. They received tailored, on‐screen feedback.

Findings

A total of 143 patients (approximately 55 per cent of all patients) began using a hand‐held computer, of whom 115 (80 per cent) answered all questions. Of these, 24 per cent reported being smokers, 7 per cent and 19 per cent were at‐risk of alcohol harm in the long and short term respectively and 14 per cent rated their overall health as poor or very poor. Most patients rated their level of satisfaction with the hand‐helds as excellent (36 per cent), very good (29 per cent) or good (24 per cent), while 89 per cent agreed to their primary care physician seeing a summary of their feedback.

Originality/value

This is the first study to evaluate the feasibility of using hand‐held computers to conduct patient screening and feedback in primary care settings.

Touch‐screen versus paper‐and‐pen questionnaires

PURPOSE

The aim of the paper is to compare the computer administration method (touch-screen) with the original paper-and-pen approach when measuring patients' perceptions of care quality.

DESIGN/METHODOLOGY/APPROACH

The study group consisted of 199 patients who responded to touch-screen and 219 who responded to paper-and-pen questionnaires, receiving care between January and March 2003 at two out-patient clinics in one county in Sweden. The response rate was 75 per cent. A modified version of the quality from the patient's perspective questionnaire was used.

FINDINGS

Two main findings emerged: first, both methods yielded almost identical results in quality of care ratings, and second, the touch-screen method was perceived to be easier to use and to take less time to complete.

ORIGINALITY/VALUE

The paper shows that both methods are acceptable, but the touch-screen method appears to be preferred by patients.

Does routine assessment and real-time feedback improve cancer patients' psychosocial well-being?

This study examined the effectiveness of giving medical oncologists immediate feedback about cancer patients' self-reported psychosocial well-being in reducing those patients' levels of anxiety, depression, perceived needs and physical symptoms. Cancer patients attending one cancer centre for their first visit were allocated to intervention (n = 42) or control (n = 38) groups. All patients completed a computerized survey assessing their psychosocial well-being while waiting to see the oncologist. Intervention patients' responses were immediately scored and summary reports were placed in each patient's file for follow-up. A total of 48 participants (25 intervention and 23 control) completed the survey four times. Intervention patients who reported a debilitating physical symptom at visit 2 were significantly less likely to report a debilitating physical symptom at visit 3 compared with control patients (OR = 2.8, P = 0.04). Reductions in levels of anxiety, depression and perceived needs among intervention patients were not significantly different to control patients. Repeated collection and immediate feedback of patient-reported health information to oncologists has potential to improve patients' symptom control, but has little impact upon emotional well-being, including those at high risk. Future research should consider providing the feedback to other health professionals and patients, and monitor the impact on the process of individual patient care.

Is a computer questionnaire of childhood asthma acceptable in general practice?

OBJECTIVES

To determine whether a previously-validated touch screen computer program of symptoms and management of childhood asthma is acceptable to parents who accompany their children to consult a GP, and to examine whether any parent characteristics are associated with acceptability.

METHODS

Conducted in general practice in Newcastle, NSW, Australia. A cross sectional pen and paper survey was given to parents of children consulting a GP after completing the computer questionnaire on childhood asthma in the waiting room. Measurements were frequencies of Likert scale responses to statements concerning the computer questionnaire, compared with demographic and personal characteristics.

RESULTS

High levels of acceptability of the asthma computer questionnaire were reported by the 198 respondents, with most being willing to do the same program once or twice a year (87%), or to do similar programs on other topics (91%). Most respondents (81%) agreed that the computer program was enjoyable, and very few (8%) would have preferred to answer the asthma questions by pen and paper rather than by computer. Two or more children accompanying the parent was the characteristic most associated with less positive responses.

CONCLUSIONS

Overall the high acceptability of this questionnaire suggests that this computerised format is an appropriate method of screening children for asthma and determining their current management. As a large component of underdiagnosis of asthma is lack of reporting to the doctor, this valid and acceptable diagnostic aid has the potential to improve detection of unreported asthma, and also to identify high-risk individuals.

Increasing smoking cessation care in a preoperative clinic: a randomized controlled trial

BACKGROUND

Evidence suggests that preoperative clinics, like other hospital outpatient clinics and inpatient wards, fail to systematically provide smoking cessation care to patients having planned surgery.

METHODS

The aim of the study was to assess the efficacy, acceptability, and cost of a multifaceted intervention to facilitate the provision of comprehensive smoking cessation care to patients attending a preoperative clinic. Two hundred ten smoking patients attending a preoperative clinic at a major teaching hospital in Australia took part in the study. One hundred twenty-four patients were randomly assigned to an experimental group and 86 patients to a usual cessation care group. A multifaceted intervention was developed that included the use of opinion leaders, consensus processes, computer-delivered cessation care, computer-generated prompts for care provision by clinic staff, staff training, and performance feedback.

RESULTS

Ninety-six percent of experimental group patients received behavioral counseling and tailored self-help material. Experimental group patients were significantly more likely than usual care patients to report receiving brief advice by nursing (79% vs. 47%; P < 0.01) and anaesthetic (60% vs. 39%; P < 0.01) staff. Experimental group patients who were nicotine dependent were also more likely to be offered preoperative nicotine replacement therapy (NRT) (82% vs. 8%; P < 0.01) and be prescribed postoperative NRT (86% vs. 0%; P < 0.01). The multifaceted intervention was found to be acceptable by staff.

CONCLUSION

A multifaceted clinical practice change intervention may be effective in improving the delivery of smoking cessation care to preoperative surgical patients.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The patient-computer interview: a neglected tool that can aid the clinician

In this article, I (1) review the process of interviewing patients by computer, (2) summarize computer-interviewing work done in 1968, (3) address the weaknesses of collecting information with the traditional history-taking methods or paper questionnaires, (4) discuss commercial software designed for computer interviewing, and (5) focus on the strengths and weaknesses of interviewing patients with a computer. The strengths of this process compared with traditional interviewing are that computer interviewing allows the physician to gather more data; gives the patient more time to complete an interview; uncovers more sensitive information; provides more adaptability to non-English-speaking patients, patients with hearing impairment, or patients who are illiterate; and provides structured information for research. The weaknesses of computer interviewing are that it generates false-positive responses, is not accepted by a minority of patients, is unable to detect nonverbal behavior, and requires changes in work flow. With the advent of an electronic medical record and the financial rewards for comprehensive history recording, the gathering of history and documentation from patients is increasingly important and favors adaptation to computer interviewing.

The application of computer touch-screen technology in screening for psychosocial distress in an ambulatory oncology setting

The objective of the study was to evaluate the acceptability and feasibility of computer touch-screen technology as a method for patients to report psychosocial functioning in an ambulatory cancer clinic. Patients participating in a randomized trial evaluating the use of self-reported psychosocial information in the clinical encounter were surveyed. The patients completed the Cancer Needs Questionnaire (CNQ), European Organization for the Research and Treatment of Cancer quality of life questionnaire (EORTC QLQ-C30) and the Beck Depression Inventory - Short Form (BDI) using a touch-screen computer. The time taken to complete the questionnaires was recorded electronically. Patients completed a seven-item pen and paper survey to assess acceptability of the process. Of the 450 patients, 244 (54%) were 60 years or older. Although over half the patients had no prior computer experience, nearly all found the touch screen easy to use and the instructions easy to understand. Each question was answered by at least 447 (99.3%) patients. The average time to complete the CNQ was 9.1 min, EORTC QLQ-C30 4.0 min and BDI 3.1 min. Factors influencing time to completion were prior use of computers, physical condition, education and overall level of needs. The study found that the use of computer touch-screen technology is an acceptable and efficient method for obtaining self-reported information on quality of life, cancer needs and psychological distress.

Social problems in oncology

A study was undertaken to describe, evaluate and categorise the social problems experienced by cancer patients. Ninety-six adult cancer patients at all stages of disease participated in either a telephone focus group discussion, a face to face focus group or an individual interview which were tape recorded and transcribed. Six experts analysed the transcripts. A total of 32 social problems were identified categorized under eight headings plus four single items. The categories were: problems with (1) managing in the home, (2) health and welfare services, (3) finances, (4) employment, (5) legal matters, (6) relationships, (7) sexuality and body image and (8) recreation. Problems with relationships and communication were the most frequently reported with financial, employment, body image and domestic problems also being widely endorsed. Female groups, younger patient groups and groups where the aim of treatment was palliative reported more social problems than other groups. Social problems are common and important to cancer patients. The social problems identified in this study will contribute to an item pool generated for developing a Social Problems Inventory that may be included in patient centred assessment as part of routine oncology practice.

A qualitative study of patients' and physicians' views about practice-based functional health assessment

BACKGROUND

Interest has increased in using patient-based measures of health status in everyday clinical practice. Patient reports of functioning and well-being have been most commonly used in clinical-practice settings at the group-level for research rather than at the individual-patient level for clinical decision-making.

OBJECTIVES

Little is known about patients' and physicians' preferences for practice-based functional health assessment. Qualitative methods were used to discover patient and physician attitudes about the use of functional health assessment tools in everyday clinical practice.

RESEARCH DESIGN

Six focus groups were conducted with 39 asthma patients who had been invited to participate in practice-based functional health assessment (FHA). Thirty in-depth, semistructured interviews were conducted with physicians in a single health maintenance organization to discover their attitudes about practice-based FHA.

SETTING

A large group-model health maintenance organization in Southeastern Wisconsin that consists of 200,000 members and 315 providers across 22 locations. Patients were selected from the Asthma Clinic and physicians were selected among all MD providers.

RESULTS

Patients identified numerous practical implementation problems with practice-based FHA, including the site of data collection, feedback on their responses, and who would have access to the data. Patients also identified several barriers and benefits of practice-based FHA. Before they would commit financial and human capital resources and time, clinicians wanted information about the effectiveness and value of practice-based FHA.

CONCLUSIONS

Several barriers to practice-based FHA were identified by patients and physicians. The evidence-based barrier identified by physicians needs to be overcome with additional intervention studies that push the envelope on several fronts including: (1) the type of tool; (2) the type of patient; (3) the type of setting; and (4) the recipients of the information. Interpretation guides and assessment linkage steps need to be developed and tested.

Randomized trial of coordinated psychosocial interventions based on patient self-assessments versus standard care to improve the psychosocial functioning of patients with cancer

PURPOSE

To determine whether making patient-reported cancer needs, quality-of-life (QOL), and psychosocial information available to the health care team, allowing coordinated specifically targeted psychosocial interventions, resulted in reduced cancer needs, improved QOL, and increased satisfaction with care received.

METHODS

Self-reported cancer needs, QOL, and psychosocial information was collected from 450 people with cancer, using standardized questionnaires via a touch-screen computer. For a randomly chosen two thirds, this information was made available to the health care team who coordinated targeted psychosocial interventions. Information from the remaining one third was not seen. Patients were assessed 2 and 6 months after randomization for changes in their cancer needs, QOL, and psychosocial functioning and satisfaction with overall care received.

RESULTS

There were no significant differences between the two arms with respect to changes in cancer needs, QOL, or psychosocial functioning between the baseline and follow-up assessments, nor with respect to satisfaction with care. However, for the subgroup of patients who were moderately or severely depressed at baseline, there was a significant reduction in depression for the intervention arm relative to the control arm at the 6-month assessment (P =.001).

CONCLUSION

Making patient-reported cancer needs, QOL, and psychosocial data available to the health care team at a single consultation together with coordinated psychosocial interventions does not seem to reduce cancer needs nor improve QOL, psychosocial functioning, or satisfaction with the care received. However, identification of patients with moderate or severe levels of depression may be valuable in reducing subsequent levels of depression.

Detecting social problems in cancer patients

Diagnosis of and treatment for cancer may not only create physical and emotional difficulties for patients but may also have an impact on social aspects of patients' lives. Screening for social problems has not become part of routine oncology practice. This may be due to lack of a suitable questionnaire. This paper presents a psychometric analysis of the Problems Checklist with a view to assessing its usefulness as a screening tool for social problems in oncology. Evaluation was undertaken using data from an earlier study of 505 patients who completed the checklist. Frequency of endorsement, missing values, factor analysis and reliability and validity analysis of the summated scales were carried out. Missing data rates ranged from 4 to 18% over the 16 items. Fourteen items were well endorsed. Factor analysis produced a four-factor structure with components labelled daily living, relationships, economics and emotions. Reliability and validity tests endorsed the factor structure with the components on economics and emotions being particularly credible. Difficulties with relationships are harder to measure and results from the analysis suggest that this is an area that warrants further investigation. The checklist is a useful tool for highlighting problems. As a tool for screening for social problems it has some limitations.

Evaluation of an instrument to assess the needs of patients with cancer. Supportive Care Review Group

BACKGROUND

This study aimed to assess the face, content, and construct validity and the internal reliability of a tool for assessing the generic needs of patients with cancer (the Supportive Care Needs Survey).

METHODS

A total of 1,492 consecutive patients attending the surgical, radiation, or medical oncology departments of 9 cancer treatment centers in New South Wales, Australia, were asked to participate. Of the 1,370 eligible patients, 1,354 (99%) consented to participate and 888 (65%) completed the survey. Eligible consenting patients were given a Supportive Care Needs Survey to complete at home and return by mail within 7 days.

RESULTS

In the assessment of construct validity, the principal components method of factor analysis identified 5 factors with eigenvalues greater than 1, which together accounted for 64% of the total variance (patients' needs in the domains of psychologic, health system and information, physical and daily living, patient care and support, and sexuality). Face and content validity were found to be high following pilot tests and tests of reading ease. Internal reliability coefficients (Cronbach alpha) of all 5 factor-based scales were found to be substantial, ranging from 0.87 to 0.97.

CONCLUSIONS

These findings suggest that the Supportive Care Needs Survey provides a reliable and valid index of the global needs of oncology patients. The standardized and widespread application of this instrument is recommended following further refinement and evaluation.

The physical and psycho-social experiences of patients attending an outpatient medical oncology department: a cross-sectional study

The aim of this study was to assess the prevalence and predictors of physical symptoms, anxiety, depression and perceived needs among patients receiving treatment at an outpatient medical oncology department using a cross-sectional survey. It was carried out at the outpatient clinic of an academic medical oncology department, which sees around 150-180 outpatients each week; 201 patients were selected. These patients answered questions to assess their levels of anxiety and depression (Hospital Anxiety and Depression Scale), perceived needs (Cancer Needs Questionnaire) and the frequency and severity of 15 physical symptoms. Fatigue, nausea, appetite loss and vomiting were the most commonly experienced and most debilitating physical symptoms. Approximately 25% of participants had borderline or clinical levels of anxiety and depression. Although relatively low levels of perceived needs were reported, physical and psychological needs were the most common. Levels of each outcome measure tended to be predictive of each other. Medical oncology outpatients experience a wide range of physical and psycho-social problems which appear, to some extent, interrelated.

Comparison of Three Methods to Assess Binge Consumption: One-Week Retrospective Drinking Diary, AUDIT, and Quantity/Frequency

Binge consumption contributes substantially to the occurrence of alcohol-related harm. Despite its importance, binge drinking is not well defined in the literature. The present study examines the proportions of respondents identified as binge drinkers by three separate measures: a 1-week retrospective drinking diary (RD), the Alcohol Use Disorders Identification Test (AUDIT), and a quantity/frequency (QF) question. Overall, AUDIT detected the highest proportion of binge drinkers, followed by QF and RD. There was also good agreement between QF and RD, as well as QF and AUDIT. Ultimately, the measure of choice should be that which provides information most appropriate to the purposes of each study.

Breaking bad news. 3: Encouraging the adoption of best practices

Steps to encourage clinicians to adopt the best practices for communicating bad news to patients are outlined. First, official, credible guidelines endorsed by key organizations or professional bodies, giving a clear message about the components and importance of the best practices, must be produced. Second, the guidelines should be disseminated; publication in journals or mailing to clinicians is unlikely to be sufficient. Third, clinicians should be provided with feedback on whether their performance meets established standards. This requires acceptable systems to collect valid and reliable performance data. Fourth, clinicians need contingencies for providing best practice care. Fifth, barriers to improvement should be explored and strategies to address them, including interactional skills training, implemented. Continuous quality assurance, commitment, and evaluations will help clinicians use the best practices for breaking bad news to patients.

Computers in community-based drug and alcohol clinical settings: are they acceptable to respondents?

The use of computer technology is not new in the delivery of health services. Previous studies have assessed the reliability and validity of computerised surveys, relative to pen and paper versions or interviews or the acceptability of computers in a range of treatment settings. Generally, these studies have reported that the reliability, validity and acceptability of computer surveys is at least comparable to more traditional survey methods. This study provides evidence for the appropriateness of using computers in community-based drug and alcohol clinical settings, reporting a high level of computer acceptability among clients. The advantages of utilising computers in clinical settings, for researchers and clinicians, are discussed.