Using patient-reported outcome measures to deliver enhanced supportive care to people with lung cancer: feasibility and acceptability of a nurse-led consultation model

Real-World Patient-Reported Outcome Measure Implementation: Challenges and Successes of a Pan-Canadian Initiative to Improve the Future of Patient-Centered Cancer Care

PURPOSE

Implementation of patient-reported outcome measures (PROMs) in routine care continues to be limited, despite their demonstrated efficacy and substantial investments. We report on the lessons learned and the challenges of the concerted implementation of the same PROMs across teams in nine provinces/territories (jurisdictions) in Canada, as well as the solutions to move implementation forward despite cost containments and the COVID-19 pandemic.

METHODS

Each team from nine jurisdictions submitted a final report describing their PROM implementation project. Reports were analyzed for themes on lessons learned, challenges, and solutions. Themes were compared for similarities and differences. The Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines were used.

RESULTS

Six key lessons learned were identified from eight challenges. To address these challenges, 27 solutions were used. The six lessons learned were as follows: Harness the power of change management, ensure consistent stakeholder engagement at all levels for success, establish buy-in as soon as possible, plan to maintain buy-in through changing circumstances, identify ways to make technology the solution, and optimal implementation includes a sustainability plan. Examples of solutions included the following: develop a multipronged, multilevel communication plan; include change management experts on the team; identify champions; restructure and reprioritize as needed; leverage existing technology; and leave a permanent trace of the project.

CONCLUSION

To our knowledge, this is the first analysis to synthesize lessons learned from real-world PROM implementation across geographically diverse jurisdictions. We identified generalizable solutions that other health care managers and policymakers can use to accelerate PROM implementation, despite pervasive implementation barriers. Future studies can integrate these solutions with methods and tools from implementation science (eg, theoretical frameworks, implementation strategies) for more successful spread and scale of PROMs.

Remote Symptom Monitoring of Patients With Advanced Lung Cancer (The ProWide Study): A Randomized Controlled Trial

PURPOSE

Remote symptom monitoring of patients with cancer has previously shown potential for improving clinical outcomes. This study aimed to evaluate the effects of remote symptom monitoring in patients with lung cancer after palliative induction treatment.

METHODS

In a Danish multicenter randomized controlled trial, patients were randomly assigned 1:1 to remote symptom monitoring (intervention arm) added to standard of care versus standard of care (control arm). Key eligibility criteria were stage III-IV lung cancer (small cell lung cancer and non-small cell lung cancer), Eastern Cooperative Oncology Group performance status ≤2, and no sign of disease progression after initial induction treatment. Patients in the intervention arm completed a weekly electronic questionnaire, assessing 14 common symptoms related to lung cancer. When a patient reported a severity exceeding a predefined threshold, the patient was subsequently contacted by phone to address potential clinical needs. Symptom monitoring was discontinued after progression. The primary outcome was overall survival (OS). Secondary measures included assessment of health-related quality of life (HRQoL).

RESULTS

Of 494 randomly assigned patients, 240 were assigned to the intervention arm and 254 were assigned to the control arm. At a median follow-up of 3.5 years, symptom monitoring did not significantly improve OS compared with standard care (hazard ratio [HR], 0.93 [95% CI, 0.75 to 1.16]; P = .53). Exploratory subgroup analyses indicated improved survival for patients treated with carboplatin/vinorelbine (HR, 0.67 [95% CI, 0.45 to 0.98]; P = .04) and in departments with previous implementation of patient-reported outcomes (HR, 0.66 [95% CI, 0.44 to 0.98]; P = .04). HRQoL analyses did not reveal clinically meaningful effects.

CONCLUSION

In the Danish health care system, remote symptom monitoring did not improve OS but led to modest improvements in HRQoL for patients with advanced lung cancer.

Patient-reported outcome measure (PROM) programs for monitoring symptoms among patients treated with immunotherapy: a scoping review

BACKGROUND

Monitoring toxicities among patients receiving immune checkpoint inhibitors using patient-reported outcome measures (PROMs) is relatively recent. This scoping review aims to guide decision making in the development of PROMs programs for patients receiving immune checkpoint inhibitor therapy.

METHODS

Four electronic databases were searched from inception to January 2024. Data on PROM programs for patients receiving immune checkpoint inhibitors (eg, PROMs used, frequency) were extracted. Two authors with established interrater reliability screened titles, abstracts, and full texts. A narrative synthesis identified patterns in the data.

RESULTS

A total of 22 articles described 16 unique multicomponent, electronic PROM programs for patients receiving immune checkpoint inhibitor therapy, mainly developed for remote monitoring of toxicities between appointments. Patients typically completed 18-26 items from the Patient-Reported Outcomes Common Terminology Criteria for Adverse Events (PRO-CTCAE) or Common Terminology Criteria for Adverse Events (CTCAE) weekly, with high adherence and satisfaction. Commonly monitored symptoms were diarrhea, fatigue, shortness of breath, cough, nausea, decreased appetite, rash, joint pain, pain, and mood. Other features of PROMs programs included clinician alerts, with some programs only flagging symptoms that had an impact on treatment. Some programs also or only sent alerts to patients to contact their clinicians and gave access to symptom management information. In terms of efficacy, the only consistent finding was an increase in quality of life.

CONCLUSIONS

The findings of this scoping review provide some indication as to which components of a PROM program are promising. However, as the evidence base for using PROMs among patients receiving immune checkpoint inhibitors is growing, many questions remain, including which symptoms to monitor, using which PROM, and at what frequency. More trials are needed to answer these questions and to determine how best to implement PROMs among patients receiving immune checkpoint inhibitor in clinical practice.

Experience or perception: What healthcare providers need when using the Utrecht Symptom Diary-4 Dimensional, a mixed-methods study

Background

The Utrecht Symptom Diary-4 Dimensional (USD-4D), an adaptation of the Edmonton Symptom Assessment System, supports healthcare providers (HCPs) in identifying, monitoring, and exploring multidimensional symptoms and needs of patients in the palliative phase. For the USD-4D to be optimally implemented in clinical palliative care, it is essential to know and understand the needs of HCPs when using it.

Objective

To identify and interpret the needs of HCPs when using the USD-4D in clinical palliative care, operationalized as perceived facilitators and barriers.

Design

An explanatory mixed-methods study with a sequential design.

Methods

Data were collected between October 2019 and September 2020. In phase I, quantitative data were collected through a survey targeting Dutch HCPs working in palliative care. Facilitators were identified as items answered positively by ⩾80% of participants, while barriers were identified as items answered negatively by ⩾20% of participants. In phase II, these identified facilitators and barriers were explored in depth through mixed composition focus groups. The Capability-Opportunity-Motivation-Behavior (COM-B) model was utilized to contextualize and interpret the perceived facilitators and barriers.

Results

A total of 122 HCPs completed the survey, with 95% of the respondents being women with a mean age of 48 years and 72% being nurses. Additionally, 53% of the respondents had no prior experience with the USD-4D. In phase II, 21 HCPs participated in focus groups. 95% of the participants were women with a mean age of 49 years and 67% being nurses. HCPs pinpointed facilitators primarily related to the potential benefits of the USD-4D for daily patient care. Conversely, the identified barriers included issues related to HCPs' behavior, knowledge gaps, uncertainty regarding their abilities and attitudes toward the USD-4D, and technical obstacles.

Conclusion

Facilitators and barriers across all facets of the COM-B model were recognized, with a notable emphasis on motivational barriers. It should be acknowledged that facilitators and barriers can evolve throughout the implementation process, underscoring the importance of viewing implementation and integration as fluid and continuous endeavors. Facilitators and barriers are closely linked to HCPs' reflective capacities, emphasizing the need for tailored intervention strategies that align with different stages of USD-4D implementation.

Validation of 11 added items of the outpatient version of the Utrecht Symptom Diary in patients receiving chemotherapy or targeted therapy

INTRODUCTION

The Utrecht Symptom Diary (USD) is a validated Dutch patient-reported outcome measurement (PROM) tool - based on the Edmonton Symptom Assessment System - to assess and monitor symptoms in cancer patients. The USD contains 11 items concerning frequently occurring symptoms in cancer patients (pain, sleeping problems, dry mouth, dysphagia, lack of appetite, abnormal stool, nausea, shortness of breath, fatigue, anxiety and depressed mood) and an item on overall well-being. For the outpatient USD 11 items concerning frequently occurring signs and symptoms in patients receiving chemotherapy and/or targeted therapy were added to the USD: taste alteration, oral pain, weight loss, diarrhoea, hair changes, skin problems, nail problems, eye problems, tingling, concentration problems and problems with sexuality. This current study aimed to evaluate the 11 added items on this treatment specific outpatient USD in cancer patients receiving intravenous chemotherapy and/or targeted therapy.

METHODS

Observational longitudinal retrospective cohort study including all adult outpatients with cancer receiving intravenous chemotherapy and/or targeted therapy in an academic hospital in the Netherlands who completed at least one outpatient USD as part of routine care (2012-2021). Relevance, comprehensiveness as well as criterion and construct validity were assessed.

RESULTS

1733 patients who completed ≥ 1 outpatient USD during intravenous chemotherapy and/or targeted therapy were included for analysis. Relevance as well as comprehensiveness of the items on the outpatient USD in this patient population was shown. Criterion validation was demonstrated for all added items of the outpatient USD - except for the item on oral pain. An additional analysis showed that mouth problems were detected with both outpatient USD items oral pain and dry mouth. Construct validity was demonstrated for the items hair changes and skin and nail problems. Construct validity on eye problems was not tested due to the low number of paired outpatient USDs.

CONCLUSIONS

The treatment specific outpatient USD is a validated PROM in outpatients with cancer receiving intravenous chemotherapy and/or targeted therapy. Considering its validity in this broad group of patients, we think the treatment-specific outpatient USD is widely applicable. In addition to providing tailored supportive symptom care, the USD-data can be used to increase knowledge about symptom burden in daily practice in this population.

From patient-reported outcomes (PROs) to family-reported outcomes (FROs): Acceptability and perceived usefulness of routine screening in cancer care

OBJECTIVES

To explore the acceptability of screening for family-reported outcomes (FROs) among cancer caregivers (unpaid family members or friends who provide support to patients with cancer) and identify from their perspective the key components of a FRO screening program.

METHODS

Using a qualitative descriptive design, semi-structured interviews were undertaken with 23 adult caregivers of people with cancer between 2020 and 2021. Interview questions focused on acceptability of FRO screening, types of FROs, timing/frequency of screening, preferred resources following screening, and communication of FROs to patients and clinicians. Participants were recruited in Canada. Interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis and constant comparison.

RESULTS

Almost all caregivers welcomed FRO screening in usual care and viewed it as an avenue toward obtaining more resources. Other potential benefits of FRO screening included increased self-reflection and role acknowledgment. Caregivers prioritized screening for emotional symptoms, and most preferred that the results be shared with the patient's treating team rather than their primary care provider. Caregivers did not want results to be shared with patients, instead favoring learning how best to discuss results with patients. Many spoke of a "one stop shop" containing all relevant information on caring for the patient (first) and for themselves (second). Opinions regarding timing and frequency of FRO screening differed. Periodic administration of FRO measures, with each one not exceeding 20 minutes, was deemed appropriate.

SIGNIFICANCE OF RESULTS

This study extends the concept of patient-reported outcome measures to caregivers, and findings can be used to guide the development of FRO screening programs.

'It is important to feel invited': what patients require when using the Utrecht Symptom Diary - 4 Dimensional, a qualitative exploration

Background

In palliative care, the Utrecht Symptom Diary - 4 Dimensional (USD-4D), a Dutch-adapted and validated patient-reported outcome measure, supports multidimensional symptom management through identification and monitoring of, as well as dialogue on symptoms and needs. For the USD-4D to optimally support patients' autonomy, it is essential to know what patients need to use it.

Objective

This study aims to identify what patients need when using the USD-4D in clinical palliative care.

Design

A generic qualitative design with primary and secondary analyses of semistructured interviews.

Methods

Patients ⩾18 years with a life-limiting illness were purposefully recruited within hospice and home care settings if they were in their last year of life as identified by the surprise question. Patients had to be aware of their life-threatening condition. Patients were selected in two tranches. In the first tranche, patients had to have completed the USD-4D at least once. The second tranche consisted of patients who were not familiar with the USD-4D in clinical practice and were interviewed in a previous study on the content validity of the USD-4D. The interviews were transcribed verbatim and were subjected to thematic analysis.

Results

Twenty-five patients were included (14 men, ages 44-87). Patients' needs when using the USD-4D were summarized in three themes: (1) feeling invited, (2) being aware of the purpose and function of the USD-4D, and (3) experiencing a personal and nonjudgmental approach.

Conclusion

For patients to optimally benefit from the USD-4D as a supportive measure of their autonomy in clinical palliative care, it is essential that they feel invited to use it. Healthcare providers are tasked with setting the right preconditions for patients to want and to be able to use the USD-4D. For patients, this means healthcare providers should always be attuned to their personal preferences when communicating the purpose and function of the USD-4D and when they enter into dialogue with them.

Patient-Reported Outcome and Experience Measures in Advanced Nursing Practice: What Are Key Considerations for Implementation and Optimized Use?

OBJECTIVE

To discuss the opportunities and challenges of implementing patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) within advanced practice nursing services in cancer care.

METHODS

This discussion paper has been informed by an environmental scan of evidence from systematic reviews and primary studies evaluating the use and implementation of PROMs and PREMs. Literature from the contexts of cancer and chronic disease, including nursing and multidisciplinary supportive care literature, has been included.

RESULTS

Advanced practice nurses are well-positioned to evaluate and respond to PROMs and PREMs data; several studies have highlighted improved patient outcomes concerning quality of life, symptom distress, and functional status within nurse-led services. Nevertheless, the implementation of PROMs and PREMs in cancer care and nurse-led services is variable. Previous studies have highlighted implementation challenges, which can hinder comparability and generalizability of PROMs and PREMs instruments. Advanced practice nurses should consider these challenges, including ways to use standardized PROM instruments. Electronic PROMs, while efficient, may exclude individuals at risk of inequity. Complex, lengthy, and frequent administration of PROMs may also overburden people living with or after cancer, with people affected by cancer expressing preference for flexible use in some studies. Therefore, the involvement of people affected by cancer in planning for PROMs/PREMs implementation may overcome this challenge. Finally, organizational considerations in implementation should address financial investments, including initial costs for technology and training and consideration of the operationalization of PROMs within existing infrastructure for the seamless utilization of PROMs data.

CONCLUSION

Despite the potential of advanced practice nursing services to enhance patient-reported outcomes and experiences, variability in the implementation of PROMs and PREMs poses challenges. Use of validated measures, electronic or paper-based instruments, and the preferences of people affected by cancer for the use of PROMs and PREMs must be carefully considered in consultation with end users for successful implementation.

IMPLICATIONS FOR PRACTICE

In planning for the implementation of PROMs and PREMs within nurse-led services, implementation risks may be mitigated through establishing clear guidelines for their use, investment in the development of the required infrastructure, user education, and rigorous implementation processes, including patient involvement in PROMs/PREMs selection.

Phenomenology: A Method for the Interpretation of Patient-Reported Outcomes

Patient-reported outcome measures (PROMs) play a central role in clinical research and patient care resulting in a plethora of standardized PROMs to measure a range of constructs, including disease symptoms, health-related quality of life, and health status (Meadows/Reaney) used in a range of settings, including the nursing environment. However, the use of PROMs in drug development and their use in healthcare evaluation do not easily marry together. In drug development, standardization of measurement is key to the interpretation of the formation at a population level with minimal biases. However, in health care, the individual patient perspective, priority, and needs should be taken into account whereas, in the clinical encounter, one has to also deal with what is particular and unique. The purpose of this paper is to describe the characteristics of the phenomenological method as a means within a mixed-method framework, to supplement participants' patient-reported outcome numeric scores with a more in-depth commentary on the essence of the lived health experiences.

Nurse-led interventions among older adults affected by cancer: An integrative review

Objective

Aging can introduce significant changes in health, cognition, function, social status, and emotional status among older adults affected by cancer. Little is known about how existing nurse-led interventions address the needs of older adults. The objective was to identify existing nurse-led interventions among older adults to optimize recovery and survivorship needs.

Methods

A integrative systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 Guidelines. Electronic databases (APA PsycINFO, CINAHL, MEDLINE, Scopus, and Google Scholar databases) were searched using key search terms. Articles were assessed for inclusion according to a pre-determined eligibility criterion. Data extraction and quality appraisal were conducted. Findings were integrated into a narrative synthesis.

Results

Twenty-one studies were included, and a total of 4253 participants were represented. There were a range of study designs: quantitative (n ​= ​10), randomised controlled trials (n ​= ​6), mixed methods studies (n ​= ​3), qualitative (n ​= ​1), and a non-randomized controlled study (n ​= ​1). Most participants had prostate cancer, with some representation in colorectal, lung, head and neck, renal, esophageal, and mixed cancer patient populations.

Conclusions

This review shows a lack of evidence on the inclusion of geriatric assessments for older people with cancer within existing nurse-led interventions. Further research is needed to test nurse-led interventions with the inclusion of geriatric assessments and their contribution to the multidisciplinary team across the cancer care continuum for various cancer patient populations.

The acceptability of implementing patient-reported measures in routine maternity care: A systematic review

INTRODUCTION

Patient-reported measures (PRMs) are becoming popular as they might influence clinical decisions, help to deliver patient-centered care, and improve health care quality. However, the limited knowledge and consensus about the acceptability of implementing PRMs in maternity care hinder their widespread use in clinical practice, and evidence-based recommendations are lacking. This systematic review aims to synthesize available evidence on the acceptability of implementing PRMs in routine maternity care.

MATERIAL AND METHODS

Literature on the implementation of PRMs in maternity care was electronically searched in six databases (PsycARTICLES, PubMed, Scopus, Web of Science, Cochrane Database of Systematic Reviews, and CINAHL), screened and selected for the topic of "acceptability". Theoretical Framework of Acceptability was used as the basic framework guiding data analysis and synthesis. Evidence was thematically analyzed and synthesized. Mixed Method Appraisal Tool and GRADE-CERQual approach were used to assess the quality of studies and evaluate the confidence in the review findings.

RESULTS

Overall, 4971 articles were screened. From 24 studies, we identified five themes regarding the acceptability of implementing PRMs in routine maternity care: (1) user's action and behavior, (2) stakeholders' attitudes, (3) perceived benefits, (4) perceived challenges and risks, and (5) stakeholders' preferences and suggestions on implementation. While pregnant and postpartum women, health professionals and other stakeholders involved in maternity care were generally positive about the implementation of PRMs in routine care and recognized the potential benefits (eg health improvement, women empowerment, care and services improvement and healthcare system advancement), they pointed out possible challenges and risks in answering PRMs questions, responding to answers, and setting up integrated information systems as well as suggested solutions in the aspects of PRMs data collection, follow-up care, and system-level management. The confidence in the review findings was moderate due to methodological limitations of included studies.

CONCLUSIONS

Available empirical evidence suggested that the use of PRMs in routine maternity care is acceptable among stakeholders involved in maternity care and the potential benefits of its integration in routine clinical practice to healthcare improvement has been recognized. However, possible challenges in data collection, follow-up care arrangement and system-level integration should be appropriately addressed.

An Overview of the Fundamentals of Data Management, Analysis, and Interpretation in Quantitative Research

OBJECTIVES

To provide an overview of three consecutive stages involved in the processing of quantitative research data (ie, data management, analysis, and interpretation) with the aid of practical examples to foster enhanced understanding.

DATA SOURCES

Published scientific articles, research textbooks, and expert advice were used.

CONCLUSION

Typically, a considerable amount of numerical research data is collected that require analysis. On entry into a data set, data must be carefully checked for errors and missing values, and then variables must be defined and coded as part of data management. Quantitative data analysis involves the use of statistics. Descriptive statistics help summarize the variables in a data set to show what is typical for a sample. Measures of central tendency (ie, mean, median, mode), measures of spread (standard deviation), and parameter estimation measures (confidence intervals) may be calculated. Inferential statistics aid in testing hypotheses about whether or not a hypothesized effect, relationship, or difference is likely true. Inferential statistical tests produce a value for probability, the P value. The P value informs about whether an effect, relationship, or difference might exist in reality. Crucially, it must be accompanied by a measure of magnitude (effect size) to help interpret how small or large this effect, relationship, or difference is. Effect sizes provide key information for clinical decision-making in health care.

IMPLICATIONS FOR NURSING PRACTICE

Developing capacity in the management, analysis, and interpretation of quantitative research data can have a multifaceted impact in enhancing nurses' confidence in understanding, evaluating, and applying quantitative evidence in cancer nursing practice.

The association between patient-reported outcomes (PROs) and patient participation in chronic care: A scoping review

OBJECTIVES

Patient-reported outcomes (PROs) are increasingly applied in chronic care due to their many functionalities and synergies with current healthcare policies. The participatory potential of PROs is especially emphasised in the Danish context. This review scrutinises the association between PRO and patient participation in chronic care.

METHODS

This scoping review adheres to PRISMA-ScR guidelines, and the synthesis is based on narrative and thematic analyses.

RESULTS

Eighty-four articles were deemed eligible. The association between PRO and patient participation regards seven themes: PRO development, response rates and patient burden, patient empowerment and self-management, display and quality of data, patient-clinician communication, shared decision-making, and organisational and attitudinal aspects. Lack of knowledge, actor attitudes, organisational setup, and technological infrastructure act as the main barriers.

CONCLUSION

The connection between PROs and patient participation is dialectic and unfolds in three phases-before, during, and after patient-clinician consultation. Knowledge regarding the last phase is particularly scarce. Henceforth, studies should address how to include a broader segment of patients, PROs participatory effects over time and PROs impact on patients' everyday lives.

PRACTICE IMPLICATIONS

The review provides knowledge concerning the association between PROs and patient participation to enhance future chronic care, research, and discussions in the area.

Guidance for the Interpretation of Continual Cuffless Blood Pressure Data for the Diagnosis and Management of Hypertension

Hypertension remains the leading risk factor for death worldwide. Despite its prevalence, success of blood pressure (BP) management efforts remains elusive, and part of the difficulty lies in the tool still used to diagnose, measure, and treat hypertension: the sphygmomanometer introduced by Samuel Siegfried Karl von Basch in 1867. In recent years, there has been an explosion of devices attempting to provide estimates of BP without a cuff, overcoming many limitations of cuff-based BP monitors. Unfortunately, the differences in underlying technologies between traditional BP cuffs and newer cuffless devices, as well as hesitancy of changing a well-implemented standard, still generate understandable skepticism about and reluctance to adopt cuffless BP monitors in clinical practice. This guidance document aims to navigate the scientific and medical communities through the types of cuffless devices and present examples of robust BP data collection which are better representations of a person's true BP. It highlights the differences between data collected by cuffless and traditional cuff-based devices and provides an initial framework of interpretation of the new cuffless datasets using, as an example, a CE-marked continual cuffless BP device (Aktiia BP Monitor, Aktiia, Switzerland). Demonstration of novel BP metrics, which have the potential to change the paradigm of hypertension diagnosis and treatment, are now possible for the first time with cuffless BP monitors that provide continual readings over long periods. Widespread adoption of continual cuffless BP monitors in healthcare will require a collaborative and thoughtful process, acknowledging that the transition from a legacy to a novel medical technology will be slow. Finally, this guidance concludes with a call to action to international scientific and expert associations to include cuffless BP monitors in original scientific research and in future versions of guidelines and standards.

Verification of the Usefulness of an Assessment and Risk Control Sheet that Promotes Management of Cancer Drug Therapy

Background: Proper management of adverse events is crucial for the safe and effective implementation of anticancer drug treatment. Showa University Hospital uses our interview sheet (assessment and risk control [ARC] sheet) for the accurate evaluation of adverse events. On the day of anticancer drug treatment, a nurse conducts a face-to-face interview. As a feature of the ARC sheet, by separately describing the symptoms the day before treatment and the day of treatment and sharing the information on the medical record, it is possible to clearly determine the status of adverse events. In this study, we hypothesized that the usefulness and points for improvement of the ARC sheet would be clarified by using and evaluating a patient questionnaire.

Methods: This study included 174 patients (144 at Showa University Hospital (Hatanodai Hospital) and 30 at Showa University Koto Toyosu Hospital (Toyosu Hospital) who underwent pre-examination interviews by nurses and received cancer chemotherapy at the outpatient center of Hatanodai and Toyosu Hospital. In the questionnaire survey, the ARC sheet’s content and quality, respondents’ satisfaction, structural strengths, and points for improvement were evaluated on a five-point scale.

Results: The patient questionnaire received responses from 160 participants, including the ARC sheet use group (132 people) and the non-use group (28 people). Unlike the ARC sheet non-use group, the ARC sheet use group recognized that the sheet was useful to understand the adverse events of aphthous ulcers (p = 0.017) and dysgeusia (p = 0.006). In the satisfaction survey questionnaire, there was a high sense of security in the pre-examination interviews by nurses using the ARC sheet.

Conclusions: The ARC sheet is considered an effective tool for comprehensively evaluating adverse events. Pre-examination interviews by nurses using ARC sheets accurately determined the adverse events experienced by patients with anxiety and tension due to confrontation with physicians.

An Evidence-Based Theory About PRO Use in Kidney Care: A Realist Synthesis

BACKGROUND

There is international interest on the use of patient-reported outcomes (PROs) in nephrology.

OBJECTIVES

Our objectives were to develop a kidney-specific program theory about use of PROs in nephrology that may enhance person-centered care, both at individual and aggregated levels of care, and to test and refine this theory through a systematic review of the empirical literature. Together, these objectives articulate what works or does not work, for whom, and why.

METHODS

Realist synthesis methodology guided the electronic database and gray literature searches (in January 2017 and October 2018), screening, and extraction conducted independently by three reviewers. Sources included all nephrology patients and/or practitioners. Through a process of extraction and synthesis, each included source was examined to assess how contexts may trigger mechanisms to influence specific outcomes.

RESULTS

After screening 19,961 references, 84 theoretical and 34 empirical sources were used. PROs are proposed to be useful for providing nephrology care through three types of use. The first type is use of individual-level PRO data at point of care, receiving the majority of theoretical and empirical explorations. Clinician use to support person-centered care, and patient use to support patient engagement, are purported to improve satisfaction, health, and quality of life. Contextual factors specific to the kidney care setting that may influence the use of PRO data include the complexity of kidney disease symptom burden, symptoms that may be stigmatized, comorbidities, and time or administrative constraints in dialysis settings. Electronic collection of PROs may facilitate PRO use given these contexts. The second type is use of aggregated PRO data at point of care, including public reporting of PROs to inform decisions at point of care and improve quality of care, and use of PROs for treatment decisions. The third type is use of aggregated PRO data by organizations, including publicly available PRO data to compare centers. In single-payer systems, regular collection of PROs by dialysis centers can be achieved through economic incentives. Both the second and third types of PRO use include pressures that may trigger quality improvement processes.

CONCLUSION

The current state of the evidence is primarily theoretical. There is pressing need for empirical research to improve the evidence-base of PRO use at individual and aggregated levels of nephrology care.

"I Am Sure That They Use My PROM Data for Something Important." A Qualitative Study About Patients' Experiences From a Hematologic Outpatient Clinic

BACKGROUND

Patient-reported outcome measures (PROMs) in clinical practice have the potential to contribute to and support shared decision-making processes by giving voice to patient concerns during consultations. However, the perspectives of patients diagnosed with chronic hematologic cancer on the use of PROMs are unknown.

OBJECTIVE

To describe how patients diagnosed with hematologic cancer experience participating in a randomized PROM intervention study, including initial invitation, completion of questionnaires, and outpatient clinic visits.

METHODS

A qualitative conceptual framework guided the study, using Interpretive Description with a focused ethnographic approach to explore patient experiences with PROMs in applied practice. Analysis was inspired by Habermas' social theory of communicative action.

RESULTS

The analysis revealed 3 predominant themes of patient experiences: that PROMs were "In the service of a good cause," "The questions are not really spot on," and "PROMs are sometimes used for something," that is, unknown to the patient.

CONCLUSIONS

The patients' experiences were dominated by the perspective of the healthcare system and by gratitude and imbalanced power relations. During completion of questionnaires, patients struggled to identify with items, and the questionnaires were associated with low content validity. When visiting the outpatient clinic, patients reported that doctors and nurses rarely discussed patients' PROMs.

IMPLICATIONS FOR PRACTICE

This study contributes knowledge of patient experiences of the integration of PROMs in hematologic outpatient clinical practice. Findings can guide further research and improve future implementation of PROMs.

What defines the comprehensive assessment of needs in palliative care? An integrative systematic review

BACKGROUND

The comprehensive assessment of needs in palliative care identifies where patients most want attention to guide clinical decisions that tailor care provision from their first encounters.

AIM

To define how and what needs are identified by the comprehensive assessment of needs in the original peer-reviewed articles in the field of palliative care.

DESIGN

An integrative systematic review as outlined by Whittemore and Knafl. Quality appraisal performed using the Mixed Methods Appraisal Tool.

DATA SOURCES

PubMed, CINAHL, PsycINFO, Web of Science databases searched through May 2019 and updated in July 2020.

RESULTS

Forty-nine articles met inclusion criteria for original articles in English or Spanish reporting comprehensive assessment of needs of adult patients receiving palliative care. The majority (41/49) of studies were moderate to high quality. Two themes were identified: (1) How a comprehensive assessment of needs should be carried out in palliative care, which reflected a preference to develop structured tools for assessment; (2) What needs of patients should be assessed in the comprehensive assessment of needs in palliative care, which conveyed a trend to assess beyond core domains - physical, psychological, social, spiritual - with information and practical most prevalent, but with substantial variation in specifying and classifying needs into domains.

CONCLUSIONS

The assessment of needs in palliative care is comprehensive but lacks consensus on the needs and domains that should be assessed by the palliative care team. Future studies should better define what needs can be standardized into the assessment to improve process of care and patient satisfaction.

Patient-Reported Outcome Measures Used in Routine Care Predict for Survival at Disease Progression in Patients With Advanced Lung Cancer

BACKGROUND

Patient-reported outcome (PRO) measures have been increasingly implemented in routine care to aid in clinical decision-making. However, the prognostic value of PRO measures as a tool for decision making is not easily interpreted by clinicians. Our aims were to explore the prognostic value of PRO measures at disease progression and the changes in PRO measures between treatment start (baseline) and disease progression.

PATIENTS AND METHODS

Since 2014, patients with lung cancer have completed an electronic version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaires C30 and LC-13 before every outpatient visit at the Department of Oncology, Hospital Unit West, Jutland, Denmark. The patients' responses were used in routine care. Patients receiving palliative antineoplastic treatment were eligible for analysis if the questionnaire had been completed at the initiation of first-line treatment and at disease progression. The prognostic value of the scores was evaluated using a Cox proportional hazard model. A P value < .01 was considered statistically significant.

RESULTS

A total of 94 screened patients were included. At disease progression, survival could be predicted from the absolute score of the global health scale, 3 functional scales (physical, role, emotional), and 7 symptom scales (fatigue, pain, dyspnea, hemoptysis, lung cancer dyspnea, chest pain). In addition, changes in hemoptysis, dysphagia, dyspnea, and chest pain predicted for survival at progression.

CONCLUSION

PRO measures used in routine care can provide clinicians with relevant prognostic information about patients with lung cancer at disease progression. These results show the potential value of PRO measures when used in clinical decision-making.

Factors Impacting Clinicians' Adoption of a Clinical Photo Documentation App and its Implications for Clinical Workflows and Quality of Care: Qualitative Case Study

BACKGROUND

Mobile health (mHealth) tools have shown promise in clinical photo and wound documentation for their potential to improve workflows, expand access to care, and improve the quality of patient care. However, some barriers to adoption persist.

OBJECTIVE

This study aims to understand the social, organizational, and technical factors affecting clinicians' adoption of a clinical photo documentation mHealth app and its implications for clinical workflows and quality of care.

METHODS

A qualitative case study of a clinical photo and wound documentation app called imitoCam was conducted. The data were collected through 20 in-depth interviews with mHealth providers, clinicians, and medical informatics experts from 8 clinics and hospitals in Switzerland and Germany.

RESULTS

According to the study participants, the use of mHealth in clinical photo and wound documentation provides numerous benefits such as time-saving and efficacy, better patient safety and quality of care, enhanced data security and validation, and better accessibility. The clinical workflow may also improve when the app is a good fit, resulting in better collaboration and transparency, streamlined daily work, clinician empowerment, and improved quality of care. The findings included important factors that may contribute to or hinder adoption. Factors may be related to the material nature of the tool, such as the perceived usefulness, ease of use, interoperability, cost, or security of the app, or social aspects such as personal experience, attitudes, awareness, or culture. Organizational and policy barriers include the available clinical practice infrastructure, workload and resources, the complexity of decision making, training, and ambiguity or lack of regulations. User engagement in the development and implementation process is a vital contributor to the successful adoption of mHealth apps.

CONCLUSIONS

The promising potential of mHealth in clinical photo and wound documentation is clear and may enhance clinical workflow and quality of care; however, the factors affecting adoption go beyond the technical features of the tool itself to embrace significant social and organizational elements. Technology providers, clinicians, and decision makers should work together to carefully address any barriers to improve adoption and harness the potential of these tools.

Understanding Clinicians' Adoption of Mobile Health Tools: A Qualitative Review of the Most Used Frameworks

BACKGROUND

Although there is a push toward encouraging mobile health (mHealth) adoption to harness its potential, there are many challenges that sometimes go beyond the technology to involve other elements such as social, cultural, and organizational factors.

OBJECTIVE

This review aimed to explore which frameworks are used the most, to understand clinicians' adoption of mHealth as well as to identify potential shortcomings in these frameworks. Highlighting these gaps and the main factors that were not specifically covered in the most frequently used frameworks will assist future researchers to include all relevant key factors.

METHODS

This review was an in-depth subanalysis of a larger systematic review that included research papers published between 2008 and 2018 and focused on the social, organizational, and technical factors impacting clinicians' adoption of mHealth. The initial systematic review included 171 studies, of which 50 studies used a theoretical framework. These 50 studies are the subject of this qualitative review, reflecting further on the frameworks used and how these can help future researchers design studies that investigate the topic of mHealth adoption more robustly.

RESULTS

The most commonly used frameworks were different forms of extensions of the Technology Acceptance Model (TAM; 17/50, 34%), the diffusion of innovation theory (DOI; 8/50, 16%), and different forms of extensions of the unified theory of acceptance and use of technology (6/50, 12%). Some studies used a combination of the TAM and DOI frameworks (3/50, 6%), whereas others used the consolidated framework for implementation research (3/50, 6%) and sociotechnical systems (STS) theory (2/50, 4%). The factors cited by more than 20% of the studies were usefulness, output quality, ease of use, technical support, data privacy, self-efficacy, attitude, organizational inner setting, training, leadership engagement, workload, and workflow fit. Most factors could be linked to one framework or another, but there was no single framework that could adequately cover all relevant and specific factors without some expansion.

CONCLUSIONS

Health care technologies are generally more complex than tools that address individual user needs as they usually support patients with comorbidities who are typically treated by multidisciplinary teams who might even work in different health care organizations. This special nature of how the health care sector operates and its highly regulated nature, the usual budget deficits, and the interdependence between health care organizations necessitate some crucial expansions to existing theoretical frameworks usually used when studying adoption. We propose a shift toward theoretical frameworks that take into account implementation challenges that factor in the complexity of the sociotechnical structure of health care organizations and the interplay between the technical, social, and organizational aspects. Our consolidated framework offers recommendations on which factors to include when investigating clinicians' adoption of mHealth, taking into account all three aspects.

The Usefulness of Patient-Reported Outcomes and the Influence on Palliative Oncology Patients and Health Services: A Qualitative Study of the Prospective Outcomes and Support Initiative

BACKGROUND

Through the British Columbia, Prospective Outcomes and Support Initiative (POSI), registered nurses collect patient-reported outcome (PRO) data during telephone follow-up with palliative oncology patients.

OBJECTIVE

The research objective was to describe the usefulness and influence of the nursing care provided through POSI follow-up on palliative patients and health services.

METHODS

We used a qualitative interpretive description approach involving the collection and analysis of semistructured interview data with 20 palliative patients and 12 oncology nurses. All participant data were subjected to an inductively derived coding framework. Analytic categories were identified and iteratively revised through constant comparative techniques to develop representative themes.

RESULTS

The accounts of patients and nurses suggest that telephone follow-up with PROs enabled the nurses to (1) focus on the priorities of patients experiencing complex health challenges, (2) manage complex symptoms, (3) ease the patient's transition home, and (4) improve access to and use of health services. Suggestions for improving POSI nurse follow-up centered on flexibility in the timing of the follow-up, creating dedicated POSI work assignments, and having additional time to personalize assessments and nursing care beyond the PRO questionnaires.

CONCLUSIONS

Nursing care employing PROs via telephone follow-up can improve palliative cancer patients' quality of life and health service use.

IMPLICATIONS FOR PRACTICE

Nurses are optimally positioned to use PROs following cancer treatment completion but require organizational resources and support to optimize patient and system outcomes.