The Initial Health Assessment: an intervention to identify the supportive care needs of cancer patients

The new challenge for improving psychosocial cancer care: shifting to a system-based approach

INTRODUCTION

There is a need to improve the psychosocial well-being of cancer patients. To date, intervention research has primarily focussed on improving psychosocial well-being through targeting singular aspects of care at the individual patient level. Sustainable, high-quality psychosocial care should address the issues faced by people diagnosed with cancer throughout the care pathway using a system-based approach.

AIMS

To examine the number of intervention trials attempting to improve psychosocial cancer care that have implemented a system-based approach.

METHOD

Five journals were selected and relevant studies across all years were extracted. Four criteria, argued to be essential characteristics of system-based change, were assessed: (1) establishing a culture change within the healthcare system/organisation, through designated leaders who endorse organisational goals; (2) adopting a multidisciplinary approach to change; (3) mapping the system and identifying points of leverage; and (4) measuring the impact of change and adapting establish feedback loops.

RESULTS

The search strategy returned 1174 citations, of which five met the inclusion criteria. Of the intervention studies identified, three met none of the four defined criteria for a systems-based intervention, one study met criterion 2 only, and one study met all four criteria, however, was not a rigorous study design.

CONCLUSIONS

This review of published psychosocial intervention trials in top-ranking psychosocial cancer care journals only found one study that met our criteria for evaluating system-based change. This is likely to be a consequence of the significant pragmatic and political barriers to conducting system-based intervention research.

A Pilot Randomized Controlled Trial of a Holistic Needs Assessment Questionnaire in a Supportive and Palliative Care Service

CONTEXT

At present, there is no widely used systematic evidence-based holistic approach to assessment of patients' supportive and palliative care needs.

OBJECTIVES

To determine whether the use of a holistic needs assessment questionnaire, Sheffield Profile for Assessment and Referral for Care (SPARC), will lead to improved health care outcomes for patients referred to a palliative care service.

METHODS

This was an open, pragmatic, randomized controlled trial. Patients (n = 182) referred to the palliative care service were randomized to receive SPARC at baseline (n = 87) or after a period of two weeks (waiting-list control n = 95). Primary outcome measure is the difference in score between Measure Yourself Concerns and Wellbeing (MYCAW) patient-nominated Concern 1 on the patient self-scoring visual analogue scale at baseline and the two-week follow-up. Secondary outcomes include difference in scores in the MYCAW, EuroQoL (EQ-5D), and Patient Enablement Instrument (PEI) scores at Weeks 2, 4, and 6.

RESULTS

There was a significant association between change in MYCAW score and whether the patients were in the intervention or control group (χ(2)trend = 5.51; degrees of freedom = 1; P = 0.019). A higher proportion of patients in the control group had an improvement in MYCAW score from baseline to Week 2: control (34 of 70 [48.6%]) vs. intervention (19 of 66 [28.8%]). There were no significant differences (no detectable effect) between the control and intervention groups in the scores for EQ-5D and Patient Enablement Instrument at 2-, 4-, or 6-week follow-up.

CONCLUSION

This trial result identifies a potential negative effect of SPARC in specialist palliative care services, raising questions that standardized holistic needs assessment questionnaires may be counterproductive if not integrated with a clinical assessment that informs the care plan.

Development and psychometric evaluation of patient needs assessment in palliative care (PNAP) instrument

OBJECTIVE

Although assessment of palliative patients' needs is a key issue in palliative care, a suitable instrument for identification of such needs is not available in Central European countries. Our objectives were to produce an adequate tool for identifying the importance and satisfaction of palliative patients' needs and to verify its psychometric properties.

METHOD

The patient needs assessment in palliative care (PNAP) instrument was constructed based on a literature review and qualitative research (focus groups, n = 5). The psychometric properties of the questionnaire were verified by a cross-sectional study. The convergent validity of the questionnaire was determined by confirmatory factor analysis. Furthermore, internal consistency, test-retest reliability, and construct validity were also tested. The qualitative research group comprised 30 participants (27 experts in palliative care, 1 patient, and 2 family members). Psychometric properties were evaluated in a group of 349 hospital inpatients terminally ill with chronic disease or cancer and receiving palliative care.

RESULTS

Based on the qualitative data analysis, a questionnaire was constructed that contained 42 items grouped into 5 domains. When testing the psychometric properties of the questionnaire, a new model containing 40 items in 7 domains was produced. Cronbach's α for the entire PNAP questionnaire was 0.89 on the importance scale and 0.80 on the satisfaction scale. Test-retest reliability was higher than 0.7 for all domains in both scales.

SIGNIFICANCE OF RESULTS

The results of tests on the psychometric properties of the PNAP questionnaire showed at least satisfactory validity and reliability, and it can be employed to assess the needs of palliative care patients in Central European countries.

Holistic assessment of supportive and palliative care needs: the evidence for routine systematic questioning

There is evidence to suggest that patients with cancer and other non-malignant chronic progressive illnesses can experience distressing symptoms, or concerns, which can often remain unrecognised. There is little disagreement that routine systematic questioning is useful in identifying supportive or palliative care needs that would otherwise not be identified. The purpose of this article is to provide an overview of holistic needs assessment in the fields of supportive and palliative care and to present evidence of the value of routine systematic questioning. Systematic questioning allows needs to be identified and addressed. There is at present no standardised systematic, evidence-based holistic approach to screening patients for supportive and palliative care needs.

First assessments by specialist cancer nurses in the community: an ethnography

PURPOSE

The aim of the study is to explore how specialist cancer nurses carry out first assessments of patients in the community, their use of the Symptoms and Concerns Checklist (SCC) and their views on first assessments.

METHODS & SAMPLE

An ethnographic approach was taken. The data were collected by use of non-participant observation of specialist nurses carrying out a first assessment of patients with cancer, followed by semi-structured interviews with six specialist nurses. Data were analysed using iterative thematic analysis.

KEY RESULTS

All the specialist nurses recognised the value of facilitating the patients' narrative. Use of the SCC was seen to jar with the overall theme of building relationships during the first assessment visit. It was recognised by the specialist nurses that the SCC was beneficial in prompting the patients to discuss psycho-social concerns.

CONCLUSIONS

This study gives insight into the conflict and ambiguity for specialist nurses when using the SCC during the first assessment visit. It confirms the SCC as beneficial in cueing some patients to identify specific concerns and for these concerns to be recognised by the specialist nurses.

Randomized pilot evaluation of the supportive care intervention "CONNECT" for people following surgery for colorectal cancer

BACKGROUND

Improvements can be made in the quality of cancer care if supportive care needs are addressed; however, there are few trials of supportive care interventions to guide policy and practice.

OBJECTIVE

This study aimed to determine the effectiveness of a nurse-delivered telephone supportive intervention (the "CONNECT" intervention).

DESIGN

This study was a pilot randomized controlled trial. Intervention group patients received 5 calls from a specialist colorectal nurse in the 6 months after hospital discharge. Each call was standardized, comprising the assessment of unmet need and the provision of information and emotional support. CONNECT was in addition to standard clinical follow-up. Patients allocated to the control group received standard follow-up only.

SETTING

This study took place at the Royal Prince Alfred Hospital, Sydney, Australia.

PARTICIPANTS

Patients (n = 75) were included who had been surgically treated for colorectal cancer (any stage).

MAIN OUTCOME MEASURES

The main outcome measures were the unmet supportive care needs, health service utilization, and quality of life at 1, 3, and 6 months postdischarge.

RESULTS

Of 87 eligible patients, 75 consented (86% consent rate). Thirty-nine patients were randomly assigned to CONNECT and 36 to usual care. At 6 months, there was a clinically relevant, but nonsignificant reduction in presentations to emergency departments (21% vs 33%; χ1 = 1.41, P = .23) and readmission to the hospital (37% vs 47%; χ1 = 0.82, P = .37) among intervention compared with control group participants. Nonsignificant differences between groups were found for all unmet supportive care need and quality-of-life scores, change scores, and trends. However, at 6 months, total quality-of-life scores were higher for intervention group patients than controls (106.0 vs 98.6). This difference (7.4) was clinically relevant. Improvements in total quality-of-life change scores demonstrated that at 6 months, improvements were more than twice as large and clinically significant in the intervention compared with the control group.

CONCLUSIONS

CONNECT has shown promising indications on health system and patient outcomes that warrant a larger study to further investigate the potential of this intervention.

Psychosocial interventions for reducing fatigue during cancer treatment in adults

BACKGROUND

Fatigue is a common symptom in cancer patients receiving active treatment. There are a limited number of reviews evaluating interventions for fatigue during active treatment, and they are restricted to patients with advanced cancer, or to patients during radiotherapy. To date there is no systematic review on psychosocial interventions for fatigue during cancer treatment.

OBJECTIVES

To evaluate if psychosocial interventions are effective in reducing fatigue in cancer patients receiving active treatment for cancer, and which types of psychosocial interventions are the most effective.

SEARCH STRATEGY

In September 2008 we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), PUBMED, MEDLINE, EMBASE, CINAHL and PsycINFO, and checked the reference lists.

SELECTION CRITERIA

Randomised controlled trials (RCTs) were included which evaluated psychosocial interventions in adult cancer patients during treatment, with fatigue as an outcome measure.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data from the selected studies, and assessed the methodological quality using several quality rating scales and additional criteria.

MAIN RESULTS

Twenty-seven studies met the inclusion criteria with a total of 3324 participants, and seven studies reported significant effects of the psychosocial intervention on fatigue. In three studies the effect was maintained at follow-up. The quality of the studies was generally moderate. Effect sizes varied between 0.17 to 1.07.The effectiveness of interventions specific for fatigue was significantly higher (80%) compared to interventions not specific for fatigue (14%). In five studies the interventions were specifically focused on fatigue, with four being effective. The five interventions were brief, consisting of three individual sessions, provided by (oncology) nurses. In general, during these interventions participants were educated about fatigue, were taught in self-care or coping techniques, and learned activity management.Of the remaining 22 studies only three were effective in reducing fatigue, and these interventions had a more general approach. These interventions were aimed at psychological distress, mood and physical symptoms, and varied strongly in duration and content.

AUTHORS' CONCLUSIONS

There is limited evidence that psychosocial interventions during cancer treatment are effective in reducing fatigue. At present, psychosocial interventions specifically for fatigue are a promising type of intervention. However, there is no solid evidence for the effectiveness of interventions not specific for fatigue. Most aspects of the included studies were heterogeneous, and therefore it could not be established which other types of interventions, or elements were essential in reducing fatigue.

Evaluation of hospital palliative care teams: strengths and weaknesses of the before-after study design and strategies to improve it

Hospital palliative care teams (HPCTs) are well established as multi-professional services to provide palliative care in an acute hospital setting and are increasing in number. However, there is still limited evaluation of them, in terms of efficacy and effectiveness. The gold standard method of evaluation is a randomised control trial, but because of methodological (e.g., randomisation), ethical and practical difficulties such trials are often not possible. HPCT is a complex intervention, and the specific situation in palliative care makes it challenging to evaluate (e.g., distress and cognitive impairment of patients). The quasi-experimental before-after study design has the advantage of enabling an experimental character without randomisation. But this has other weaknesses and is prone to bias, for example, temporal trends and selection bias. As for every study design, avoidance and minimisation of bias is important to improve validity. Therefore, strategies of selecting an appropriate control group or time series and applying valid outcomes and measurement tools help reducing bias and strengthen the methods. Special attention is needed to plan and define the design and applied method.

Informational needs of patients and perceived adequacy of information available before and after treatment of cancer

To examine the various concerns of patients after being diagnosed with cancer as well as the availability of information to address concerns from the time of diagnosis to the completion of treatment, we analyzed data from a longitudinal study of 731 adults recently diagnosed with cancer. Concerns about the effectiveness and side effects of treatment and family stress were most common after diagnosis. Information about the diagnosis and treatment plan was readily available to patients, but information addressing social, lifestyle, and financial concerns was less available. Significantly more information was desired regarding the long-term implications of treatment and disease.

Financial stress and strain associated with terminal cancer--a review of the evidence

Financial circumstances are a significant influence on the quality of life for older people and may be important to health and wellbeing at the end of life. The aim of this study is to review the evidence for the existence and consequences of financial stress and strain at the end of life for people dying with cancer. We conducted a systematic search of four electronic databases for studies, providing data on illness-related financial burden (stress), or perception of financial hardship (strain), from patients with terminal cancer or their caregivers. Twenty-four papers were identified from 21 studies published in English between 1980 and 2006, the majority (14) of cross-sectional design. Financial stress was reported in all 13 studies from the USA (median 33%, range 10-66%), but only four sought measures of financial strain. In the USA, specific social consequences, such as moving house or change in employment to cope with caregiving, were reported in four of these studies; one of these also noted changes in treatment choices and avoidance of care for other family members. In studies from outside the USA, there is a dearth of data on financial stresses and the consequences of this for the household, despite widespread reporting of financial strain. To fill a gap in our understanding and improve holistic palliative care, researchers need to ask the questions about the consequences of financial stresses and strain for the health and wellbeing of the household.

Quality-of-life assessment in palliative care

Quality-of-life assessment can be a helpful tool in ensuring optimal palliative care. To adequately assess quality of life, it must be first defined and subsequently measured. This article outlines several of the instruments available to measure quality of life, including the Karnofsky Score, Edmonton Symptom Assessment, Memorial Symptoms Assessment Scale, European Organization for Research and Treatment of Cancer Questionnaire, Quality and Quantity of Life Short Questionnaire, and Cambridge Palliative Assessment Schedule. Use of these instruments in the context of goal-setting and family meetings as well as common pitfalls in quality-of-life assessment are outlined.

Psychosocial needs assessment among an underserved, ethnically diverse cancer patient population

Little attention has been directed towards identifying and addressing the psychosocial needs of ethnic minority and underserved cancer patients. This study describes the development of a psychosocial needs survey and patterns and predictors of need among an ethnically diverse underserved cancer patient population in Bronx, New York. A 34-item psychosocial needs assessment survey was developed to assess 4 categories of need: Informational, Practical, Supportive, and Spiritual. A total of 248 oncology outpatients (48% non-Hispanic whites, 25% African Americans; 19% Hispanic) completed the survey in oncology clinic waiting rooms. The survey demonstrated high internal consistency and face validity. Ethnicity was the sole predictor of needs (P < .02), even after controlling for education, time since diagnosis, treatment status, marital status, and age. The mean percentage of needs endorsed by African Americans, Hispanics, and non-Hispanic whites respectively was 81%, 85%, 70% for Informational; 63%, 68%, 36% for Practical; 69%, 73%, 48% for Supportive; and 49%, 60%, 31% for Spiritual needs. This needs assessment offers clear directions in which to focus QOL intervention efforts among underserved and ethnic minority cancer patients. Cancer 2007. (c) 2006 American Cancer Society.

Patients' needs assessment in cancer care: a review of assessment tools

BACKGROUND

The assessment of patients' needs for care is a critical step in achieving patient-centred cancer care. Tools can be used to assess needs and inform care planning. This review discusses the importance of systematic assessment of needs in routine care and the contribution tools can make to this process.

METHOD

A rapid appraisal was undertaken to identify currently available tools for patient assessment in cancer care through searches conducted with Medline and CINHAL databases. It focused on tools for the systematic assessment of individual patients' needs for help, care or support, to be used for clinical purposes-not for research or other purposes. Tools that focused on a single domain of care such as psychosocial needs were excluded, as were studies of patient satisfaction. A wide list of search terms was used, with references stored and managed using bibliographic software.

RESULTS

In all, 1,803 papers were identified from the initial search, with 91 papers found to be relevant; although 36 tools were identified, only 15 tools were found to fit our criteria. These were appraised for their validity, reliability, responsiveness to change and feasibility, including acceptability to patients. The process of their development and psychometric properties were reasonably well documented, but data on how feasible they were to use in practice was scarce. Each tool met some but not all the widely accepted criteria for validity, reliability, responsiveness and burden. None were found to be complete for all dimensions of needs assessment. Most have not been sufficiently well tested for use in routine care.

CONCLUSION

There is a need to continue to develop and test tools that have the attributes necessary for effective practice and to research their effects on the quality of supportive cancer care.

Oncology professionals and patient requests for cancer support services

OBJECTIVE

To examine the kinds of psychosocial support services that cancer patients most often request across a multidisciplinary sample of currently practicing U.S. oncological health care professionals (OHCPs) representative of a typical cancer care team.

PARTICIPANTS

Primary data collection. A randomly selected sample of 1,180 OHCPs (44% physicians, 24% nurses, 32% social workers) who were active members of their respective oncological associations completed a brief four-page mailed survey during the spring of 2001.

METHODS

Cross-sectional, descriptive study. Descriptive statistics were computed for all study variables. ANOVA procedures were used to examine demographic difference between respondents and non-respondents. Frequencies were calculated for patient inquires for cancer support services inquiries, and logistic regression was used to evaluate professional group differences on inquiries. Chi-square statistics were used to test for significant differences between professional groups.

RESULTS

Approximately 94% of OHCPs were asked about cancer-related support services by their patients. Quantitative data indicated that information and education about cancer (72%), support groups (65%), and hospice referral (52%) were paramount among patient concerns. Qualitatively, comments about transportation, lodging during treatment, and alternative medicine reflected the general sentiment that basic needs and opportunities for options may still be unmet. Patient inquiries for services varied significantly by professional group (p<.001).

CONCLUSION

This information reflects the need for a multidisciplinary perspective and will be useful for planning patient-based cancer education and support initiatives, refining existing programs, and targeting materials to specific oncological professionals.