Self-management goals of cancer survivors with an ostomy

OBJECTIVES

Ostomies due to cancer surgery impose complex and enduring care challenges that necessitate cancer survivors" self-management. The objective of this analysis is to evaluate ostomates' self- management goals using a qualitative approach.

METHODS

A multi-site randomized controlled trial testing the Ostomy Self-Management Training program (OSMT) was delivered via telehealth to a group of cancer survivors with an ostomy randomized to either the OSMT program with goal setting or usual care (UC), without goal setting. Goals were classified by type and frequency according to a modified City of Hope Health-Related Quality of Life framework (physical, psychological, social, spiritual, ostomy-specific, and healthcare quality domains), using a directed and systematic content analysis approach.

RESULTS

The 524 self-management goals analyzed by domain frequencies physical (29.4%), ostomy specific (29.0%) and social well-being (25.0%) were predominant. Managing other health issues (7.6%), psychological issues (6.0%), and spiritual well-being issues (3.0%) were next. Common self-management themes were ostomy care independence (87.5%), handling cancer-related issues (62.5%), achieving acceptance (56.2%), resuming physical activity (43.0%), and maintaining fluid/diet balance (43.0%).

DISCUSSION/CONCLUSION

Goal-setting offers insights into self-management concerns of cancer survivors with ostomies. Results demonstrate the broad aspects of self-management ostomates face.

PRACTICE IMPLICATIONS

Self-management training with patient goal-setting may be used to help ostomates with cancer and their health care providers identify areas for needed education and support.

Clinical and Demographic Differences Among Cancer Survivors With Ostomies With and Without Informal Caregivers

Informal caregivers have an essential role for cancer survivors (CS). There may be important clinical and demographic differences between CS with ostomies based on caregiver status. Our aim was to identify items that may lead to future recommendations and interventions for CS with ostomies. This is a secondary analysis of 216 CS with ostomies that were enrolled in a clinical trial. Baseline data collected included demographics, clinical characteristics, and surveys (patient activation, self-efficacy, City of Hope Quality of Life - Ostomy). These factors were compared based on caregiver status using chi-squared analysis and t-tests. Logistic regression was used to examine the factors that affect the likelihood of having a caregiver. Most participants had an identified caregiver (57%; 124/216). There was no difference in age based on caregiver status (mean 64.4 and 62.0 for those with and without a caregiver, respectively). Of those with a caregiver, 66.9% were males, 79.0% were partnered, and 87.1% were white. Those with caregivers had a higher prevalence of diabetes (p < 0.001), heart disease (p = 0.002), and mobility issues (p = 0.002). Survivors with caregivers had both higher incomes (p = 0.012) and levels of education (p = 0.049). The only difference in survey measures was those with a caregiver were more successful at getting help when needed (p = .045). Differences in gender and comorbidities of CS with caregivers demand further investigation. Interventions such as encouraging CS without caregivers to utilize available sources of social support, including other survivors with ostomies, may improve their care and quality of life.

Adapting to the burdens of care: a telehealth program for cancer survivors with ostomies

PURPOSE

An ostomy introduces to cancer survivors new demands for self-care and healthcare resource use. A curriculum that teaches ostomates self-management skills may affect survivors' use of resources.

METHODS

A prospective randomized trial comparing usual care (UC) with an Ostomy Self-Management Training (OSMT) program delivered by telehealth was conducted in patients with ostomies due to cancer. The intervention occurred over 5 weeks with survey administration at baseline, program completion, and 6 months after completion. Quantitative data were analyzed using a mixed-effects logistic model to predict mean values of resource and service use. Responses to the open-ended question were coded and analyzed with directed content analysis.

RESULTS

One hundred and sixty-seven subjects (89 in the OSMT arm and 78 in the UC arm) completed the questionnaire at all time points. The changes in likelihoods of emptying one's ostomy bag > 8 times/week and of incurring any out-of-pocket costs on accessories were 14% greater for the intervention group (p = .029 and p = .063, respectively). Qualitative analysis reveals among the OSMT arm an increase in the proportion of ostomy-specific comments and a decrease in the same metric among the UC arm. Common themes included learning to work with equipment, dealing with gas build-up and finding well-fitting clothing.

CONCLUSIONS

There are some indications that participants in this structured telehealth program are more active in ostomy self-care. The reported ostomy self-care activities, healthcare consumables, and healthcare services reported by both groups illustrate the complexity of survivorship care following ostomy surgery. National Clinical Trial Identifier: NCT02974634.

Clinical Decision Support for Symptom Management in Lung Cancer Patients: A Group RCT

CONTEXT

Clinical guidelines are available to enhance symptom management during cancer treatment but often are not used in the practice setting. Clinical decision support can facilitate the implementation and adherence to clinical guidelines. and improve the quality of cancer care.

OBJECTIVES

Clinical decision support offers an innovative approach to integrate guideline-based symptom management into oncology care. This study evaluated the effect of clinical decision support-based recommendations on clinical management of symptoms and health-related quality of life (HR-QOL) among outpatients with lung cancer.

METHODS

Twenty providers and 179 patients were allotted in group randomization to attention control (AC) or Symptom Assessment and Management Intervention (SAMI) arms. SAMI entailed patient-report of symptoms and delivery of recommendations to manage pain, fatigue, dyspnea, depression, and anxiety; AC entailed symptom reporting prior to the visit. Outcomes were collected at baseline, two, four and six-months. Adherence to recommendations was assessed through masked chart review. HR-QOL was measured by the Functional Assessment of Cancer Therapy-Lung questionnaire. Descriptive statistics with linear and logistic regression accounting for the clustering structure of the design and a modified chi-square test were used for analyses.

RESULTS

Median age of patients was 63 years, 58% female, 88% white, and 32% ≤high school education. Significant differences in clinical management were evident in SAMI vs. AC for all target symptoms that passed threshold. Patients in SAMI were more likely to receive sustained-release opioids for constant pain, adjuvant medications for neuropathic pain, opioids for dyspnea, stimulants for fatigue and mental health referrals for anxiety. However, there were no statistically significant differences in HR-QOL at any time point.

CONCLUSION

SAMI improved clinical management for all target symptoms but did not improve patient outcomes. A larger study is warranted to evaluate effectiveness.

Cancer survivors' greatest challenges of living with an ostomy: findings from the Ostomy Self-Management Telehealth (OSMT) randomized trial

OBJECTIVES

An ostomy results in lifelong quality of life changes for a cancer survivor. We describe the greatest challenges reported from a randomized trial of cancer survivors with stomas (ostomies).

METHODS

Cancer survivors with ostomies participating in a multi-site randomized prospective trial of an Ostomy Self-Management Telehealth (OSMT) program versus usual care (UC) were surveyed at six months post accrual. An open-ended question requested greatest challenges after ostomy surgery. Quantitative descriptive and qualitative analyses were used to examine greatest challenges reported.

RESULTS

A total of 118 trial participants identified greatest challenges with 55 in the OSMT and 63 in the UC. Six conceptual domains were used to code comments-physical, psychological, social, and spiritual quality of life; ostomy-specific issues, and healthcare issues. The OSMT contributed 187 comments, and UC contributed 235 comments. Ostomy specific issues and social well-being had the most comments overall with UC contributing more comments in all domains except physical well-being. Word Clouds revealed post-operative and treatment-related issues and going out in public as the most common challenges in both groups. Word Clouds compared types of ostomies revealing bowel function challenges (colostomy group), difficulties going out in public (ileostomy group), and positive support (urostomy group).

CONCLUSIONS

Fewer challenges submitted by the OSMT group provide the beginning evidence of the OSMT program impact. Dominant challenges across both groups were social well-being and ostomy care. Challenges varied by type of ostomy. Findings support long-term care and support for all cancer survivors with ostomies.

TRIAL REGISTRATION

NCT02974634.

Ostomy Self-Management Training Intervention for Cancer Survivors: Technology-Related Findings from a Randomized Trial

BACKGROUND

Ostomy Self-Management Telehealth (OSMT) intervention by nurse-educators and peer-ostomates can equip new ostomates with critical knowledge regarding ostomy care. A telehealth technology assessment aim was to measure telehealth engineer support requirements for telehealth technology related (TTR) incidents encountered during OSMT intervention sessions held via a secure cloud videoconferencing service, "Zoom for Healthcare".

OBJECTIVE

This paper examines technology challenges, issues, and opportunities encountered in the use of telehealth in the setting of an intervention RCT for cancer survivors living with a permanent ostomy.

METHODS

The Arizona Telemedicine Program (ATP) provided telehealth engineering support for 105 scheduled 90-120-minute OSMT sessions over a two-year period. OSMT groups included up to 15 participants, comprised of four to six ostomates, four to six peer-ostomates, two nurse educators, and one telehealth engineer. OSMT session TTR incidents were recorded contemporaneously in detailed notes by research study staff. TTRs were categorized and tallied.

RESULTS

102 of 105 (97%) OSMT sessions were completed as scheduled. Three OSMT sessions were not held due to non-technology related reasons. Of the 93 ostomates who participated in OSMT sessions, 80 (86%) completed their OSMT curriculum. TTR incidents occurred in 35.3% of completed sessions with varying disruptive impact. Zero sessions were cancelled or rescheduled due to TTR incidents. Disruptions resulting from TTR incidents were minimized by following TTR incident prevention and incident response plans.

CONCLUSIONS

Telehealth videoconferencing technology can enable ostomates to participate in ostomy self-management education by incorporating dedicated telehealth engineering support. OSMT potentially greatly expands availability of ostomy self-management education to new ostomates.

CLINICALTRIAL

Ostomy Telehealth For Cancer Survivors (PCORI) NCT02974634.

Cardiotoxicity in Hematopoietic Stem Cell Transplant: Keeping the Beat

INTRODUCTION

The number of hematopoietic stem cell transplants (HSCTs) performed in the United States and worldwide is increasing. Cardiac events have been well described in HSCT, and the incidence and type of cardiac events have not changed over recent decades.

PATIENTS AND METHODS

This study adds to the body of evidence in describing the incidence and type of cardiac events experienced by an allogeneic and autologous HSCT population at a single institution from 2012 to 2017.

RESULTS

Sixty-five (9.8%) patients experienced cardiac events, including atrial arrhythmia (N = 39), acute heart failure (N = 9), acute coronary syndrome (N = 7), and new onset hypertension (N = 9), with a few instances of bradycardia, ventricular arrhythmia, pericardial effusion, and pericarditis. Our multivariable regression analysis identified age (older), creatinine (higher), and history of coronary artery disease to significantly correlate with risk of cardiac event (P = .005, P = .039, and P = .038, respectively). A subgroup analysis of those patients experiencing a cardiac event found pre-transplant atrial dilation by trans-thoracic echocardiogram to correlate with increased risk of atrial arrhythmia (33.8% vs. 9.7%; P = .03). Patients developing a CE had an increased risk of death within 1 year (11% vs. 32%; P < .001).

CONCLUSION

We review our results in context of other important HSCT cardiac studies to illuminate the most relevant factors of medical history, laboratory data, and cardiac measurements that will identify patients at higher risk, allowing for intervention to improve HSCT outcomes.

Patterns of palliative symptom management (PSM) medication use at end-of-life (EoL) among Medicare beneficiaries with advanced lung cancer (advLC)

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Background: Patients with advLC experience high symptom burden; undertreatment may result in poor quality of life for patients and caregivers. Hospice enrollment often happens late or not at all, yet little is known about EoL outpatient PSM medication use in the non-hospice setting. Methods: Using SEER-Medicare linked registry and claims data, we selected decedents diagnosed with advLC between 2008-2013 who survived ≥6 months (death between 2008-2014). Using non-hospice claims, we identified receipt of oral and parenteral medications to manage symptoms such as pain (any pain medications, any opioids), nausea/ vomiting and dyspnea at 6 (EoL-6) and 1 (EoL-1) months prior to death. Antiemetics were excluded if concurrent with chemotherapy (CTx). T-tests compared sample proportions receiving PSM between EoL-6 and EoL-1. Logistic regression estimated associations between PSM medication receipt at EoL-1 and patient demographic characteristics, comorbidity, and ongoing CTx or radiation. Results: We identified 16,246 decedents: mean age 77 years, 50% male, and 81% non-Hispanic white. PSM medication for individual symptom areas increased from EoL-6 to EoL-1 [Table]. Adjusted results indicate that pain medication receipt was higher for females, and patients with multimorbidity, dual Medicare/Medicaid, higher poverty, living in rural areas, and receiving concurrent radiation but lower among those with increasing age and for non-white race/ethnicity groups. We saw similar trends for PSM using opioids, and for emotional distress, and dyspnea. Conclusions: Among patients with advLC at EoL, medication use for symptom relief was common and increasing toward EoL-1. Lower use by males, older adults, and non-whites may reflect poor access or poor patient-provider communication. Further research is needed to assess adequacy of PSM in the outpatient setting. [Table: see text]

Improving family caregiver and patient outcomes in lung cancer surgery: Study protocol for a randomized trial of the multimedia self-management (MSM) intervention

OBJECTIVE

To describe the study protocol of the Multimedia Self-Management (MSM) intervention to prepare patients and family caregivers (FCGs) for lung cancer surgery.

DESIGN

The study is a five-year, single site, randomized controlled trial of 160 lung cancer surgery FCG and patient dyads (320 total participants), comparing intervention and attention control arms.

SETTING

One National Cancer-Institute (NCI) designated comprehensive cancer center in Southern California.

PARTICIPANTS

Patients who are scheduled to undergo lung cancer surgery and their FCGs are enrolled as dyads only.

INTERVENTION

Based on the Chronic Care Self-Management Model (CCM), the intervention is a nurse-led, caregiver-based, multimedia care program for lung cancer surgery. Its primary focus is to help FCGs develop self-management skills related to their caregiving role through goal setting, proactive planning, building problem-solving skills, and accessing family support services. The intervention also supports dyads to prepare for surgery and post-operative recovery at home. It includes videos, print, web-based, and post-discharge telephone support.

MAIN OUTCOME MEASURES

FCG and patient psychological distress and QOL; FCG burden and preparedness for caregiving; FCG and patient healthcare resource use (in-home nursing care, urgent care/ER visits, readmissions).

ANALYSIS

Repeated measures ANCOVA statistical design will be used, removing variances prior to examining mean squares for the group by occasion interactions, and co-varying the baseline scores. In addition, structured equation modeling (SEM) will assess whether mediating and moderating factors are associated with outcomes. ClinicalTrials.gov Identifier: NCT03686007.

Using the RE-AIM framework for dissemination and implementation of psychosocial distress screening

OBJECTIVE

To evaluate the RE-AIM framework's effect on retention of participants and implementation outcomes of a 5-year cancer research education programme on psychosocial distress screening in cancer centres across the United States.

METHODS

A one-group pre-/post-test design was used to evaluate the programme on participant retention and implementation outcomes at 6, 12 and 24 months after enrolling in the programme (baseline) and analysed using descriptive statistics.

RESULTS

Seventy-two cancer centres participated in four cohorts. Participant retention was 100%. At baseline and 24 months, respectively, 52 (72%) and 64 (88%) of the cancer centres had formulated a psychosocial distress screening policy; 51 (71%) and 70 (98%) had started screening in more than one clinic/population; 15 (21%) and 45 (63%) had started auditing health records for documentation of screening. Each outcome rate improved at the cancer-centre level over the 24 months.

CONCLUSION

RE-AIM can be used as a framework for cancer research education programmes. Future research is needed on the use of a randomised adaptive design to test the optimal support for implementation of quality care standards according to cancer centres' needs.

The prevalence and related factors associated with psychosocial distress among 420 hospitalised lung cancer patients in China: A case study

Previous studies have reported high prevalence of psychosocial distress among lung cancer patients in Western countries, but the prevalence of distress in Chinese patients is not established. The study objectives were to report the prevalence of and factors associated with psychosocial distress in a sample of hospitalised patients in China and to implement distress screening in one thoracic specialty department. In this cross-sectional study, adult patients completed a self-reported demographic and clinical questionnaire and the distress thermometer with the problem list. Distress was dichotomised (high vs. low) and compared. Regression analyses were used to determine which variables were associated with psychosocial distress. One hundred eighty-six of 420 patients (38.6%) reported distress ≥4/10. They were unemployed, had New Rural Cooperative Medical System (NRCMS) insurance and Stage IV cancer. NRCMS insurance contributed to the likelihood of high distress and worry. Patients reported significant psychosocial distress during hospitalisation related to practical, emotional and physical problems. In this case study, staff reported they screened consecutive patients but there were no available referrals after discharge. We concluded it may be premature to screen patients for distress prior to instituting resources to establish services. To do otherwise is premature in ensuring patients' relief.

A Prospective Longitudinal Investigation of Spousal Bereavement Examining Parkes and Weiss’ Bereavement Risk Index

The purpose of this study was (a) to describe spousal bereavement both prospectively and longitudinally and (b) to examine the validity of the Bereavement Risk Index (BRI) published by Parkes and Weiss (1). Psychological distress was measured in 46 subjects across five time intervals beginning prior to a spousal death from lung cancer and ending 25 months after the death using the Brief Symptom Inventory (BSI) (2). The hypothesis that the BRI discriminates between bereaved spouses at high and low risk for psychological distress was supported by measurements taken within two months of the patient's diagnosis (prior to death), at 6 weeks following the death, and at 6 and 13 months thereafter. These findings support the need for early identification of individuals at high risk for negative bereavement outcomes even prior to the spousal death.

Randomized Trial of Exercise on Quality of Life in Women With Ovarian Cancer: Women's Activity and Lifestyle Study in Connecticut (WALC)

Background

Ovarian cancer survivors experience a wide range of treatment side effects that can negatively affect health-related quality of life (HRQOL). Physical activity has been shown to improve HRQOL and cancer-related fatigue (CRF) for other cancer survivors; however, no large randomized controlled trial (RCT) has been conducted for ovarian cancer.

Methods

This study examined the impact of a six-month RCT of exercise vs attention control on change in HRQOL (Short Form Health Survey-36) and CRF (Functional Assessment of Cancer Therapy-Fatigue Scale) in ovarian cancer survivors. Women (n = 144) were randomly assigned to study arms between May 1, 2010, and March 20, 2014. All statistical tests were two-sided.

Results

A total of 74 women were randomly assigned to exercise and 70 to attention control. A total of 113 (78.5%) of the participants completed the six-month assessment. Adherence to the exercise intervention was excellent (166.0±66.1 minutes/week in the exercise arm). At six months, women in the exercise arm had improved physical HRQOL (SF-36 Physical Component Summary Score) compared with the control arm, 1.8 (SD = 1.1) vs -2.0 (SD = 1.2) , respectively (group difference = 3.7, SD = 1.2, 95% confidence interval [CI] = 0.7 to 6.8, P = .02). No group differences were seen for change in mental HRQOL. There was a statistically significant improvement in the fatigue score (Functional Assessment of Cancer Therapy-Fatigue) for exercisers (4.0, SD = 1.1, 95% CI = 1.8 to 6.2, P < .001) but not for controls (1.2, SD = 1.2, 95% CI = -1.1 to 3.5, P = .31), with a between-group difference of 2.8 (SD = 1.5, 95% CI = -0.2 to 5.7, P = .06).

Conclusions

We found a six-month home-based, telephone-delivered exercise intervention of primarily brisk walking to be associated with improved physical HRQOL in women with ovarian cancer. Given that higher HRQOL and exercise have both been associated with overall survival in women diagnosed with ovarian cancer, oncologists and primary care providers should recommend and refer women diagnosed with ovarian cancer to clinic- or community-based exercise programs.

An Evidence-Based Tool for Safe Configuration of Electronic Health Records: The eSafety Checklist

BACKGROUND

Electronic health records (EHRs) are transforming the way health care is delivered. They are central to improving the quality of patient care and have been attributed to making health care more accessible, reliable, and safe. However, in recent years, evidence suggests that specific features and functions of EHRs can introduce new, unanticipated patient safety concerns that can be mitigated by safe configuration practices.

OBJECTIVE

This article outlines the development of a detailed and comprehensive evidence-based checklist of safe configuration practices for use by clinical informatics professionals when configuring hospital-based EHRs.

METHODS

A literature review was conducted to synthesize evidence on safe configuration practices; data were analyzed to elicit themes of common EHR system capabilities. Two rounds of testing were completed with end users to inform checklist design and usability. This was followed by a four-member expert panel review, where each item was rated for clarity (clear, not clear), and importance (high, medium, low).

RESULTS

An expert panel consisting of three clinical informatics professionals and one health information technology expert reviewed the checklist for clarity and importance. Medium and high importance ratings were considered affirmative responses. Of the 870 items contained in the original checklist, 535 (61.4%) received 100% affirmative agreement among all four panelists. Clinical panelists had a higher affirmative agreement rate of 75.5% (656 items). Upon detailed analysis, items with 100% clinician agreement were retained in the checklist with the exception of 47 items and the addition of 33 items, resulting in a total of 642 items in the final checklist.

CONCLUSION

Safe implementation of EHRs requires consideration of both technical and sociotechnical factors through close collaboration of health information technology and clinical informatics professionals. The recommended practices described in this checklist provide systems implementation guidance that should be considered when EHRs are being configured, implemented, audited, or updated, to improve system safety and usability.

An Automated Intervention Did Not Improve Adherence to Oral Oncolytic Agents While Managing Symptoms: Results From a Two-Arm Randomized Controlled Trial

CONTEXT

An increasing number of oral cancer treatments require patient adherence and symptom self-management.

OBJECTIVES

The report presents the effects of a medication reminder and symptom management intervention directed at patients initiating new oral oncolytic agents.

METHODS

Patients (N = 272) were recruited at six comprehensive cancer centers, interviewed over the telephone after oral agent initiation, and randomized to either standard care or a medication reminder and symptom management intervention. In the intervention arm, the automated system called patients daily to remind them about taking their medications and weekly to assess 18 symptoms and refer patients to a printed Medication Management and Symptom Management Toolkit. Severity of 18 symptoms was also assessed during telephone interviews at Week 4 (midintervention), Week 8 (postintervention), and Week 12 (follow-up). Adherence was measured using the relative dose intensity, the ratio of dose taken by patient out of dose prescribed by the oncologist, and assessed using pill counts at Weeks 4, 8, and 12 and prescribing information from medical records.

RESULTS

The relative dose intensity was high and did not differ by trial arm. Symptom severity was significantly lower (P < 0.01) in the experimental arm at Week 8 but not at Weeks 4 or 12.

CONCLUSION

Adherence may be less of a problem than originally anticipated, and intervention was not efficacious possibly because of already high rates of patient adherence to oral oncolytic medication during first 12 weeks. Longer follow-up in future research may identify subgroups of patients who need interventions to sustain adherence.

Managing Psychosocial Distress: Lessons Learned in Optimizing Screening Program Implementation

The estimated prevalence of psychosocial distress in cancer patients is 29.6% to 43.4%. Psychosocial distress is associated with depression, a common comorbidity in cancer patients. Untreated distress can contribute to early morbidity and mortality and can worsen other comorbidities. In 2012, the American College of Surgeons (ACoS) Commission on Cancer (CoC) required accredited cancer centers to integrate psychosocial distress screening into cancer care by the end of 2015. Uptake of screening has been minimal, with only 47% to 73% of eligible patients being screened. The Screening for Psychosocial Distress Program (SPDP) is a 2-year educational and implementation-support program designed to help cancer care clinicians meet the ACoS CoC mandate. Through the SPDP, we have trained cancer care clinicians on how to optimize the distress screening process to increase the likelihood that patients' distress will be detected, evaluated, and triaged. We report here on our "lessons learned" and the optimal strategies to promote institutions' adoption of distress screening.

Preparing Cancer Patients and Family Caregivers for Lung Surgery: Development of a Multimedia Self-Management Intervention

The surgical treatment of lung malignancies often results in persistent symptoms, psychosocial distress, and decrements in quality of life (QOL) for cancer patients and their family caregivers (FCGs). The potential benefits of providing patients and FCGs with preparatory education that begins in the preoperative setting have been explored in multiple medical conditions, with positive impact observed on postoperative recovery, psychological distress, and QOL. However, few studies have explored the benefits of preparatory educational interventions to promote self-management in cancer surgery, including lung surgery. This paper describes the systematic approach used in the development of a multimedia self-management intervention to prepare cancer patients and their FCGs for lung surgery. Intervention development was informed by (1) contemporary published evidence on the impact of lung surgery on patients and FCG, (2) our previous research that explored QOL, symptoms, and caregiver burden after lung surgery, (3) the use of the chronic care self-management model (CCM) to guide intervention design, and (4) written comments and feedback from patients and FCGs that informed intervention development and refinement. Pilot-testing of the intervention is in process, and a future randomized trial will determine the efficacy of the intervention to improve patient, FCG, and system outcomes.

Psychosocial Distress Screening: An Educational Program's Impact on Participants' Goals for Screening Implementation in Routine Cancer Care

BACKGROUND

Psychosocial distress screening is a quality care standard in cancer care. Screening implementation may be facilitated by an educational program that uses goals to evaluate progress over time.

OBJECTIVES

This article describes the content and design of the Screening for Psychosocial Distress Program (SPDP), reports on its delivery to 36 paired participants, and evaluates its effects on distress screening activities and goals.

METHODS

The SPDP used a one-group pre-/post-test design. It was delivered at 2 workshops and 10 conference calls during a two-year period. Data on screening and goal achievement were collected at 6, 12, and 24 months. Data on the quality of dyads' relationships were collected at 24 months.

FINDINGS

At 24 months, all 18 dyads had begun screening. Dyads reported working effectively together and being supportive of the other member of the dyad while achieving their goals for implementing psychosocial distress screening.

Lymphedema in ovarian cancer survivors: Assessing diagnostic methods and the effects of physical activity

BACKGROUND

Lymphedema is a poorly understood side effect of gynecologic cancer treatment. This study was designed to determine the prevalence of lower limb lymphedema (LLL) in a sample of ovarian cancer survivors via 3 different diagnostic methods and to assess the effect of a randomized exercise intervention.

METHODS

Physically inactive ovarian cancer survivors (n = 95) were enrolled in a 6-month randomized trial of exercise (primarily brisk walking) versus attention control. LLL was measured at baseline and 6-month visits via a self-report questionnaire, optoelectronic perometry, and an evaluation by a certified lymphedema specialist.

RESULTS

LLL prevalence ranged from 21% to 38% according to the diagnostic method, and there was substantial agreement between the self-report questionnaire and the lymphedema specialist evaluation (κ = 0.61). There was no agreement between the evaluation with optoelectronic perometry and the specialist evaluation. With LLL defined by any method, the baseline prevalence was 38% in both groups. At 6 months, both groups experienced a decreased LLL prevalence: 28% in the exercise group and 35% in the control group. There was no difference in the change in lymphedema prevalence between the 2 groups (P = .64). Body mass index was a significant predictor of LLL.

CONCLUSIONS

With a potential prevalence of LLL as high as 40%, further evaluation of diagnostic methods is required to better characterize this side effect of ovarian cancer treatment. No adverse effect of exercise on LLL was found. Further research is strongly needed to evaluate predictors of LLL and the effects of exercise on LLL in order to develop effective physical activity recommendations for women with ovarian cancer. Cancer 2018;124:1929-37. © 2018 American Cancer Society.

An Employee-Centered Care Model Responds to the Triple Aim: Improving Employee Health

Health care expenditures, patient satisfaction, and timely access to care will remain problematic if dramatic changes in health care delivery models are not developed and implemented. To combat this challenge, a Triple Aim approach is essential; Innovation in payment and health care delivery models is required. Using the Donabedian framework of structure, process, and outcome, this article describes a nurse-led employee-centered care model designed to improve consumers' health care experiences, improve employee health, and increase access to care while reducing health care costs for employees, age 18 and older, in a corporate environment.

Adapting an Evidence-Based Pediatric Acute Asthma Exacerbation Severity Assessment Tool for Pediatric Primary Care

INTRODUCTION

The purposes of this project were (a) to examine criteria derived from evidence-based pediatric acute asthma exacerbation assessment tools, asthma scores, and the acute asthma prediction rule validated and used in the emergency department and (b) to adapt these criteria for pediatric primary care.

METHOD

The three stages of the project included (a) identification of criteria in a literature review, (b) validation of the criteria by an expert panel, and (c) adaptation of the criteria in the design of an assessment tool.

RESULTS

The criteria were validated and adapted in the design of The Pediatric Acute Asthma Exacerbation Severity Assessment and Disposition Decision-Making Tool for Pediatric Primary Care.

DISCUSSION

The adaptation of criteria derived from the evidence and validated by an expert panel will inform and guide clinicians in assessing severity and support decision making in determining disposition of pediatric patients presenting with an acute asthma exacerbation in primary care.

Costs of an ostomy self-management training program for cancer survivors

OBJECTIVE

To measure incremental expenses to an oncologic surgical practice for delivering a community-based, ostomy nurse-led, small-group, behavior skills-training intervention to help bladder and colorectal cancer survivors understand and adjust to their ostomies and improve their health-related quality of life, as well as assist family caregivers to understand survivors' needs and provide appropriate supportive care.

METHODS

The intervention was a 5-session group behavior skills training in ostomy self-management following the principles of the Chronic Care Model. Faculty included Wound, Ostomy, and Continence Nurses (WOCNs) using an ostomy care curriculum. A gender-matched peer-in-time buddy was assigned to each ostomy survivor. The 4-session survivor curriculum included the following: self-management practice and solving immediate ostomy concerns; social well-being; healthy lifestyle; and a booster session. The single family caregiver session was coled by a WOCN and an ostomy peer staff member and covered relevant caregiver and ostomate support issues. Each cohort required 8 weeks to complete the intervention. Nonlabor inputs included ostomy supplies, teaching materials, automobile mileage for WOCNs, mailing, and meeting space rental. Intervention personnel were employed by the University of Arizona. Labor expenses included salaries and fringe benefits.

RESULTS

The total incremental expense per intervention cohort of 4 survivors was $7246 or $1812 per patient.

CONCLUSIONS

A WOCN-led group self-help ostomy survivorship intervention provided affordable, effective, care to cancer survivors with ostomies.

Ostomy telehealth for cancer survivors: Design of the Ostomy Self-management Training (OSMT) randomized trial

PURPOSE

An ostomy adversely affects health-related quality of life (HRQOL) in a diverse population of cancer survivors and their caregivers. Hit-or-miss ostomy care, nurse counseling, and community referral have been the primary modes of self-management education and support in the peri-operative setting. Few evidence-based, systematic ostomy self-management programs are available to ensure optimal post-operative care. This paper describes the study design of a telehealth-based Ostomy Self-management Training (OSMT) program for cancer survivors and their caregivers.

METHODS

The study is a three-year, randomized trial that tests the effectiveness of the OSMT program on survivor activation, self-efficacy, and HRQOL. The intervention integrates goal setting and problem-solving approaches to enhance survivor activation and self-efficacy to carry out ostomy care. The curriculum is delivered via four group sessions administered by trained ostomy certified nurses (WOCNs) and peer ostomates. An additional session is offered to caregivers to address their needs in relation to ostomy care. Telehealth approaches through videoconferencing are used to enhance program delivery to participants in three different geographic areas across two time zones. Participants join sessions via real-time videoconferencing from their homes.

CONCLUSIONS

The OSMT program has high potential to make a positive impact on the unique physical, psychological, social, and spiritual needs of cancer survivors living with a permanent ostomy. The study design, process, and telehealth approach contributes to the success of future dissemination efforts of the intervention into diverse clinical and community settings.

Applying the Chronic Care Model to Support Ostomy Self-Management: Implications for Oncology Nursing Practice

BACKGROUND

Living with an ostomy requires daily site and equipment care, lifestyle changes, emotional management, and social role adjustments. The Chronic Care Ostomy Self-Management Training Program (CCOSMTP) offers an ostomy self-management curriculum, emphasizing problem solving, self-efficacy, cognitive reframing, and goal setting.

OBJECTIVES

The qualitative method of content analysis was employed to categorize self-reported goals of ostomates identified during a nurse-led feasibility trial testing the CCOSMTP.

METHODS

Thirty-eight ostomates identified goals at three CCOSMTP sessions. The goals were classified according to the City of Hope Health-Related Qualify of Life Model, a validated multidimensional framework, describing physical, psychological, social, and spiritual ostomy-related effects. Nurse experts coded the goals independently and then collaborated to reach 100% consensus on the goals' classification.

FINDINGS

A total of 118 goals were identified by 38 participants. Eighty-seven goals were physical, related to the care of the skin, placement of the pouch or bag, and management of leaks; 26 were social goals, which addressed engagement in social or recreational roles and daily activities; and 5 were psychological goals, which were related to confidence and controlling negative thinking. Although the goals of survivors of cancer with an ostomy are variable, physical goals are most common in self-management training.

A Multimedia Self-management Intervention to Prepare Cancer Patients and Family Caregivers for Lung Surgery and Postoperative Recovery

BACKGROUND

The purpose of this study was to evaluate the feasibility and acceptability of a multimedia self-management (MSM) intervention to prepare patients and family caregivers for lung surgery.

PATIENTS AND METHODS

This is a quasi-experimental, 2-group, sequential enrollment pilot study of a 4-session multimedia intervention (audio/visual + print) to enhance self-management and quality of life (QOL) for patients and family caregivers. The intervention, Preparing for Lung Surgery, begins before surgery, and continues through hospitalization and discharge, with 2 telephone support sessions after discharge. Outcomes were assessed before surgery (preintervention), at discharge, and 2 to 4 weeks postdischarge (postintervention). Patient outcomes were assessed using the Functional Assessment of Cancer Therapy-General (QOL), MD Anderson Symptom Inventory and Functional Assessment of Cancer Therapy-Pulmonary Symptom Index (symptoms), self-efficacy, surgery-related knowledge, and patient activation. Family caregiver outcomes included City of Hope-QOL-Family (QOL), Caregiver Burden Scale, and knowledge. Paired t tests were used for exploratory evaluations of score changes from pre- to postintervention.

RESULTS

Sixty participants (38 patients, 22 family caregivers) enrolled in the study (70% accrual). Postintervention scores were significantly improved for patients' emotional QOL (P = .001). Trends for improvements were observed for patient self-efficacy, surgery-related knowledge, and activation. Family caregivers' surgery-related knowledge was significantly improved (P = .02). Overall, participants were highly satisfied with the acceptability/usability of the intervention (3.6-3.7 of 4.0).

CONCLUSION

A standardized MSM intervention was feasible and acceptable in supporting readiness and preparedness for lung surgery and postoperative recovery. A larger randomized trial is needed to verify the impact of the MSM intervention on patient/family caregiver outcomes and health care resource use.

The Measurement of Transitions in Cancer Scale

BACKGROUND AND PURPOSE

Health-illness transitions are changes in life phase, situation, or status related to shifts between health and illness. We report on the development and psychometric evaluation of the Measurement of Transitions in Cancer Scale (MOT-CA), a 7-item instrument that assesses extent and management of a range of transitions experienced by cancer patients.

METHODS

We identified content domains, developed operational definitions, generated items, conducted expert review (n = 7) and cognitive interviews (n = 13), and tested MOT-CA with our target population (n = 105).

RESULTS

MOT-CA has content and convergent validity and a 2-factor structure consisting of Personal Transitions (physical, emotional, social, spiritual; eigenvalue = 2.994) and Care Transitions (cancer status, treatment, approach to care; eigenvalue = 1.444).

CONCLUSION

Although additional testing is indicated, the MOT-CA is valid, brief, and acceptable.

Quality of life and self-management strategies after gastroesophageal cancer surgery

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Background: Gastroesophageal cancer surgery can result in significant morbidity and decreased quality of life (QOL). The profound physical changes and symptoms that affect eating/digestion can substantially alter psychological and social well-being. We aimed to describe QOL and dietary/behavioral self-management strategies after gastroesophageal cancer surgery. Methods: Patients who were 6-12 months post-resection completed surveys for QOL (EORTC-QLQ-C30), symptoms (EORTC-QLQ-OES18 or QLQ-STO22), diet modifications, and behavioral adjustments. Scores for validated measures were calculated according to guidelines, and summarized using descriptive statistics. Results: 31 patients (11 esophagectomy, 20 gastrectromy) participated in the study. Surgical approach was 71% minimally invasive (laparoscopic, robotic). Patients reported clinically meaningful (≥10 point difference) worse mean scores compared to reference population means for physical (73.3/100 esophagectomy, 78.3/100 gastrectomy vs. 89.8/100 reference populations), role (63.6/100, 73.3/100 vs. 84.7/100), and social functioning (62.1/100, 75.0/100 vs. 87.5/100). Eating problems (48.5/100) was the worst symptom for esophagectomy patients. Thereafter, problems with taste, cough, reflux, and dysphagia were reported frequently. For gastrectomy patients, eating problems was also the worst symptom (28.2/100), followed by body image disturbance, dry mouth, and pain. Time to comfort with eating after surgery was between 3-12 months. The most common behavioral adjustments include chewing food completely (96%), eating multiple meals per day (90%), controlling meal portions (87%), staying or sitting upright after meals (71%), staying at or close to home more (64%), and eating out less (55%). Conclusions: QOL is greatly reduced after gastroesophageal cancer surgery. Eating problems and associated symptoms persist 6-12 months after surgery. Patients used multiple self-management strategies to control eating problems and symptoms. These strategies varied greatly, suggesting that personalized interventions are necessary to help patients adjust to eating after surgery and improve QOL.

Frailty determinants in two long-term care settings: Assistant living facilities and home and community-based programs

There is limited knowledge on differences in frailty among residents in assisted living facilities (ALF) and home and community-based services (HCBS). This study used a retrospective cross-sectional design to compare frailty determinants in two long-term care settings. The HCBS setting had a greater proportion of positive responses to 9 of 14 frailty indicators. The ALF setting had a greater proportion to only 2 of the 14 frailty indicators. The finding that the HCBS setting had a significantly greater proportion of participants with positive frailty indicators as compared to the ALF setting suggests the degree of frailty risk is different by health care setting.

Missing Domains of Lung Transplant Patient Selection

The goal of consistent, predictable, and improved outcomes has continued to elude the scientific community in the 30 years since lung transplantation became the procedure of choice for patients with terminal, nonmalignant lung disease.

Background:

Although there is consensus regarding disease-specific indications for lung transplant, ambiguity remains regarding how patient-specific attributes should influence lung transplant candidacy. This study had 3 aims (1) to establish the missing domains of the interdisciplinary assessment of the lung transplant candidate, (2) to have these domains validated by an international panel of lung transplant experts, and (3) to recommend the next step for inclusion of these domains into the lung transplant candidate selection process.

Methods:

Three levels of evidence were reviewed. A search for standards and guidelines, a comprehensive literature review, and a validation of domains by experts were conducted.

Results:

Seven domains of patient attributes were identified as relevant to lung transplant patient selection: cognitive performance, frailty, psychological factors, self-efficacy, social support, quality of life, and sociodemographic factors. Within each domain, several elements were identified to be incorporated in the process of patient assessment.

Conclusion:

Assessment of the missing domains and elements should be incorporated into the interdisciplinary lung transplant evaluation process. Standardized recognition and reporting of the patient-specific attributes will inform the work of individual transplant programs and the international transplant community. Further study is needed to associate these patient attributes with transplant outcomes. Improved understanding is needed regarding how nurses assess lung transplant candidates and how they communicate their findings within interdisciplinary settings.

Application of Community-Based Participatory Research Methods to a Study of Complementary Medicine Interventions at End of Life

Community-based participatory research (CBPR) principles can be successfully applied to the design and implementation of a complementary medicine study for adults with end-stage AIDS. The Yale Prevention Research Center partnered with Leeway, Inc., an AIDS-dedicated nursing facility, and other academic and clinical entities to conduct a randomized, controlled pilot trial of meditation and massage on quality of life at the end of life. Using CBPR principles, a methodology was developed that was scientifically rigorous, highly respectful, and acceptable to the 91% minority study population. Using continuous, open communication among all involved parties, challenges were satisfactorily addressed in a timely manner. Fifty-eight residents (97% of those eligible) with end-stage AIDS participated from November 2001 to September 2003. Subjects received 1-month interventions of meditation, massage, combined meditation and massage, or standard care. The study of quality-of-life in end-stage AIDS poses unique challenges well met by applying CBPR principles to an academic-community research partnership.

Evolution of a 90-day model of care for bundled episodic payments for congestive heart failure in home care

The Centers for Medicare and Medicaid Services Innovation Center's Episode-Based Payment initiatives propose a large opportunity to reduce cost from waste and variation and stand to align hospitals, physicians, and postacute providers in the redesign of care that achieves savings and improve quality. Community-based organizations are at the forefront of this care redesign through innovative models of care aimed at bridging gaps in care coordination and reducing hospital readmissions. This article describes a community-based provider's approach to participation under the Bundled Payments for Care Improvement initiative and a 90-day model of care for congestive heart failure in home care.

Design of an Evidence-Based "Second Victim" Curriculum for Nurse Anesthetists

The "second victim" phenomenon--when a healthcare provider experiences adverse events because of the adverse events of a patient--is not well known or understood among healthcare professionals, including Certified Registered Nurse Anesthetists (CRNAs). No published research is currently available on the impact of second victim specifically in CRNAs, but it is known that second victim poses major challenges for healthcare professionals. Therefore, it is important to acknowledge its occurrence and to develop an educational curriculum based on the available evidence in order to promote peer and organizational support infrastructures. A comprehensive literature review was conducted, 6 educational domains on second victim were developed, and an expert panel validated the content.

A chronic care ostomy self-management program for cancer survivors

BACKGROUND

Individuals with ostomies experience extensive changes in health-related quality of life (HRQOL) and daily routine. Patients and families are typically forced to use trial and error to improve self-management.

METHODS

This is a longitudinal one-group design pilot study of a five-session ostomy self-care curriculum based on the Chronic Care Model to improve HRQOL and self-management for cancer survivors with ostomies. Participants were surveyed to evaluate each session. Multiple instruments were administered to examine outcomes at baseline, post-intervention, and at 6-month follow-up (Patient Activation Measure, self-efficacy, Hospital Anxiety and Depression Scale, Ways of Coping, Group Health Association of America Satisfaction with ostomy care survey, and the City of Hope Quality of Life Ostomy). Changes from pre-intervention to post-intervention and pre-intervention to follow-up were evaluated with paired t-tests. Text responses were coded and evaluated for important themes and recommendations.

RESULTS

Thirty-eight subjects participated in the study. Most had a history of rectal cancer (60.5%) or bladder cancer (28.9%). Participants rated the overall program high (4.4-4.8 on 5-point scale). Text feedback indicated that participants enjoyed the group forums, wanted more participants, and more hands-on training. Scores on multiple surveys were shown to be improved and sustained, including patient activation (p = 0.0004), self-efficacy (p = 0.006), total HRQOL (p = 0.01), physical well-being (p = 0.005), and social well-being (p = 0.002). Survivor anxiety was significantly reduced by follow-up (p = 0.047).

CONCLUSIONS

This self-management ostomy program can help cancer survivors with ostomies adapt to their stoma. Initiating this program in the community setting would be beneficial to many cancer survivors.

Health information needs and preferences in relation to survivorship care plans of long-term cancer survivors in the American Cancer Society's Study of Cancer Survivors-I

PURPOSE

Survivorship care plans (SCPs) provide cancer patients and health care providers with a treatment summary and outline of recommended medical follow-up. Few studies have investigated the information needs and preferred sources among long-term cancer survivors.

METHODS

Cancer survivors of the ten most common cancers enrolled in the longitudinal Study of Cancer Survivors-I (SCS-I) completed a survey 9 years post-diagnosis (n = 3138); at time of diagnosis of the SCS-I cohort, SCPs were not considered usual care. We assessed participants' current desire and preferred sources for information across ten SCP items and evaluated factors associated with information need 9 years after diagnosis.

RESULTS

The proportion of long-term cancer survivors endorsing a need for cancer and health information 9 years post-diagnosis ranged from 43 % (cancer screening) to 9 % (consequences of cancer on ability to work). Print media and personalized reading materials were the most preferred information sources. Younger age, higher education, race other than non-Hispanic white, later cancer stage, having breast cancer, having ≥2 comorbidities, and self-reporting poor health were associated with greater informational need (p < 0.05).

CONCLUSIONS/IMPLICATIONS FOR CANCER SURVIVORS

Long-term cancer survivors continue to report health information needs for most SCP items and would prefer a print format; however, level of need differs by socio-demographic and cancer characteristics. Cancer survivors who did not previously receive a SCP may still benefit from receiving SCP content, and strategies for enabling dissemination to long-term survivors warrant further investigation.

The five steps of comprehensive psychosocial distress screening

Despite the growing recognition of the impact psychosocial distress has on the quality of life of patients with cancer, the implementation of the National Comprehensive Cancer Network (NCCN) Distress Management Guidelines and the mandate of evidence-based policy for routine distress screening continue to lag. To speed adoption of the guideline, the American Psychosocial Oncology Society (APOS) and Yale School of Nursing (YSN) launched the Screening for Psychosocial Distress Program in 2014. The program resulted in the development of five steps necessary to carry out routine psychosocial distress screening. The steps are consistent with the NCCN Distress Management Guidelines and the new criterion for accreditation by the American College of Surgeons (ACS) Commission on Cancer as of 2015. These five steps are as follows: (1) screening, (2) evaluating, (3) referring, (4) following up, and (5) documenting and quality improvement. The purpose of this article is to summarize the detailed procedure of the five steps for cancer care professionals-including oncologists, nurses, psychiatrists, psychologists, and social workers-so they can manage psychosocial distress efficiently in their own clinical environments.

An Advanced Practice Nurse Coordinated Multidisciplinary Intervention for Patients with Late-Stage Cancer: A Cluster Randomized Trial

BACKGROUND

Early palliative care provided through a palliative care consultative service is effective in enhancing patient outcomes. However, it is unknown whether the integration of palliative care as part of routine comprehensive cancer care improves patients' self-reported clinical outcomes.

OBJECTIVE

The objective of this study was to evaluate the effects of a multidisciplinary coordinated intervention by advanced practice nurses at the clinic level on outcomes with patients newly diagnosed with late-stage cancer.

METHODS

A clustered, randomized, controlled trial design was used. Four disease-specific multidisciplinary clinics were randomized to the 10-week intervention (gynecologic and lung clinics) or to enhanced usual care (head and neck and gastrointestinal clinics). Patient primary outcomes (symptoms, health distress, depression, functional status, self-reported health) were collected at baseline and one and three months, and secondary outcomes were collected one and three months postbaseline. General linear mixed model analyses with a covariance structure of within-subject correlation was used to examine the intervention's effect.

RESULTS

The sample included 146 patients with newly diagnosed late-stage cancers. We found no differences between the two groups on the primary patient-reported outcomes at one and three months postbaseline; however, physical and emotional symptoms remained stable or significantly improved from baseline for both groups. Overall, secondary outcomes remained stable within the groups.

CONCLUSION

In this translational study, we demonstrated that if patients newly diagnosed with late-stage cancer were managed by disease-specific multidisciplinary teams who palliated their symptoms, providing whole-patient care, patient outcomes remained stable or improved.

Supporting commission on cancer-mandated psychosocial distress screening with implementation strategies

PURPOSE

The American College of Surgeons Commission on Cancer (CoC) has set psychosocial distress screening as a new patient care standard to be met by 2015. The standard requires CoC-accredited cancer centers to integrate and monitor distress screening and, when needed, refer patients to psychosocial health care services. We describe the uptake of distress screening reported by applicants to a distress screening cancer education program and the degree of and barriers to implementation of distress screening programs reported by selected participants.

MATERIALS AND METHODS

This cross-sectional study collected quantitative data online from applicants to the program between August 1 and November 15, 2013, described by frequencies, percentages, and measures of central tendency, and qualitative data in person from accepted participants on February 13, 2014, analyzed using an integrated approach to open-ended data.

RESULTS

Applications were received from 70 institutions, 29 of which had started distress screening. Seven of 18 selected applicant institutions had not begun screening patients for distress. Analysis of qualitative data showed that all participants needed to create buy-in among key cancer center staff, including oncologists; to decide how to conduct screening in their institution in a way that complied with the standard; and to pilot test screening before large-scale rollout.

CONCLUSION

Fourteen months before the compliance deadline, fewer than half of applicant institutions had begun distress screening. Adding implementation strategies to mandated quality care standards may reduce uncertainty about how to comply. Support from key staff members such as oncologists may increase uptake of distress screening.

Incorporating patient-reported outcomes to improve emotional distress screening and assessment in an ambulatory oncology clinic

PURPOSE

Assessment of distress and well-being of patients with cancer is not always documented or addressed in a clinical visit, reflecting a need for improved psychosocial screening.

METHODS

A multidisciplinary team completed process mapping for emotional distress assessment in two clinics. Barriers were identified through cause-and-effect analysis, and an intervention was chosen. Patient-reported outcomes were collected over 6 months using the validated National Comprehensive Cancer Network Emotional Distress Thermometer (EDT) paper tool. The American Society of Clinical Oncology Quality Oncology Practice Initiative (QOPI) measures were compared before and after intervention.

RESULTS

During 6 months, a total of 864 tools were collected from 1,344 patients in two ambulatory clinics (64%). Electronic medical record documentation of distress increased from 19.2% to 34% during the 6 months before and after intervention. QOPI measures showed an increase in emotional well-being documentation. Of 29 new and 835 return patients, 62% indicated mild distress (EDT, 0 to 3), 18% moderate (EDT, 4 to 6), and 11% severe (EDT, 7 to 10). The average distress score of new patients was significantly higher than that of return patients (5.39 [n = 26] v 2.52 [n = 754]; P < .001). The top problems for patients with moderate and severe distress were worry, fatigue, pain, and nervousness; depression and sadness were particularly noted in patients reporting severe distress. Eleven percent of patients were referred to the social worker on site.

CONCLUSION

A pilot intervention collecting Patient-reported outcomes in two ambulatory clinics led to increase in psychosocial distress screening followed by sustained improvement, indicated by both process and QOPI measures.

Do depressed newly diagnosed cancer patients differentially benefit from nurse navigation?

OBJECTIVE

To examine whether the effects of a nurse navigator intervention for cancer vary with baseline depressive symptoms.

METHOD

Participants were enrolled in a randomized controlled trial of a nurse navigation intervention for patients newly diagnosed with lung, breast or colorectal cancer (N=251). This exploratory analysis used linear regression models to estimate the effect of a nurse navigator intervention on patient experience of care. Models estimated differential effects by including interactions between randomization group and baseline depressive symptoms. Baseline scores on the 9-item Patient Health Questionnaire (PHQ) were categorized into 3 groups: no depression (PHQ=0-4, N=138), mild symptoms of depression (PHQ=5-9, N=76) and moderate to severe symptoms (PHQ=10 or greater, N=34). Patient experience outcomes were measured by subscales of the Patient Assessment of Chronic Illness Care (PACIC) and subscales from an adaptation of the Picker Institute's patient experience survey at 4-month follow-up.

RESULTS

With the exception of the PACIC subscale of delivery system/practice design, interaction terms between randomization group and PHQ-9 scores were not statistically significant.

CONCLUSIONS

The intervention was broadly useful; we found that it was equally beneficial for both depressed patients and patients who were not significantly depressed in the first 4 months postdiagnosis. However, because of the small sample size, we cannot conclude with certainty that patients with depressive symptoms did not differentially benefit from the intervention.

Feasibility of using algorithm-based clinical decision support for symptom assessment and management in lung cancer

CONTEXT

Distressing symptoms interfere with the quality of life in patients with lung cancer. Algorithm-based clinical decision support (CDS) to improve evidence-based management of isolated symptoms seems promising, but no reports yet address multiple symptoms.

OBJECTIVES

This study examined the feasibility of CDS for a Symptom Assessment and Management Intervention targeting common symptoms in patients with lung cancer (SAMI-L) in ambulatory oncology. The study objectives were to evaluate completion and delivery rates of the SAMI-L report and clinician adherence to the algorithm-based recommendations.

METHODS

Patients completed a web-based symptom assessment and SAMI-L created tailored recommendations for symptom management. Completion of assessments and delivery of reports were recorded. Medical record review assessed clinician adherence to recommendations. Feasibility was defined as 75% or higher report completion and delivery rates and 80% or higher clinician adherence to recommendations. Descriptive statistics and generalized estimating equations were used for data analyses.

RESULTS

Symptom assessment completion was 84% (95% CI=81-87%). Delivery of completed reports was 90% (95% CI=86-93%). Depression (36%), pain (30%), and fatigue (18%) occurred most frequently, followed by anxiety (11%) and dyspnea (6%). On average, overall recommendation adherence was 57% (95% CI=52-62%) and was not dependent on the number of recommendations (P=0.45). Adherence was higher for anxiety (66%; 95% CI=55-77%), depression (64%; 95% CI=56-71%), pain (62%; 95% CI=52-72%), and dyspnea (51%; 95% CI=38-64%) than for fatigue (38%; 95% CI=28-47%).

CONCLUSION

The CDS systems, such as SAMI-L, have the potential to fill a gap in promoting evidence-based care.

A differential item function analysis of somatic symptoms of depression in people with cancer

BACKGROUND

The overlap of somatic symptoms of depression with symptoms of cancer treatment is widely acknowledged and studied. However, this literature provides little guidance for clinicians as to whether these items should be used in assessing depression. The current study examined the appropriateness of using somatic items for assessment of depression in people with cancer.

METHODS

People with newly diagnosed breast, lung or colorectal cancer (n=251) completed the Patient Health Questionnaire-9 (PHQ9) shortly after cancer diagnosis but before cancer treatment (baseline), 4 months later, typically during or shortly after treatment, and 12 months later. Pharmacy data was used to classify participants as having low somatic symptoms or high somatic symptoms. Differential item function (DIF) compared the functioning of the somatic items of the PHQ9 in the low vs. high symptom groups and the chemotherapy vs. no chemotherapy groups at the 4-month assessment.

RESULTS

Significant DIF was not found on any of the four somatic items of the PHQ9 and differences in the item parameters of the somatic items were not consistent across the groups. However, fatigue and sleep indicated only mild depression. Only removing the fatigue item greatly affected the number screening positive for depression at 4 months (8.3%) but removing the other somatic items did not have as large an effect. Only one participant at baseline screened positive for depression by somatic symptoms alone (no psychological symptoms) and no participants screened positive by somatic symptoms alone at 4 months and 12 months.

LIMITATIONS

The sample size was small for DIF and consisted of mostly women with breast cancer.

CONCLUSIONS

Somatic symptoms of depression can continue to be administered to people with cancer, however the fatigue and sleep items should be used with caution.