Prioritizing Chinese Medicine Clinical Research Questions in Cancer Palliative Care: International Delphi Survey

Palliative Care Research and Clinical Practice Priorities in the United States as Identified by an Interdisciplinary Modified Delphi Approach

Background: Palliative care demands in the United States are growing amid a comparatively small workforce of palliative care clinicians and researchers. Therefore, determining research and clinical practice priorities is essential for streamlining initiatives to advance palliative care science and practice. Objectives: To identify and rank palliative care research and clinical practice priority areas through expert consensus. Design: Using a modified Delphi method, U.S. palliative care experts identified and ranked priority areas in palliative care research and clinical practice. Priorities were thematically grouped and analyzed for topic content and frequency; univariate analysis used the median of each priority item ranking, with a cutoff median of ≤8 indicating >76% agreement for an item's ranking. Results: In total, 27 interdisciplinary pediatric and adult palliative care experts representing 19 different academic institutions and medical centers participated in the preliminary survey and the first Delphi round, and 22 participated in the second Delphi round. The preliminary survey generated 78 initial topics, which were developed into 22 priority areas during the consensus meeting. The top five priorities were (1) access to palliative care, (2) equity in palliative care, (3) adequate financing of palliative care, (4) provision of palliative care in primary care settings, and (5) palliative care workforce challenges. Conclusions: These expert-identified priority areas provide guidance for researchers and practitioners to develop innovative models, policies, and interventions, thereby enriching the quality of life for those requiring palliative care services.

Quality of life in terminally ill cancer patients: what is the role of using complementary and alternative medicines?

BACKGROUND AND PURPOSE

Cancer is the world's second greatest cause of mortality and a leading cause of death in both developed and developing countries. Patients employ a number of complementary and alternative medicine (CAM) methods to deal with the problems and difficulties of cancer, which can have an impact on their quality of life (QOL). The aim of the present study was to assess the correlation between QOL and the use of different CAM methods in terminally ill cancer patients.

METHODS

This was a cross-sectional study. In southern Iran, 238 individuals with advanced cancer were studied in oncology centers and doctors' offices. During the months of January to August 2021, patients were selected using convenience sampling. A demographic information questionnaire, the EORTC core quality of life questionnaire, and the CAM questionnaire were used to collect data.

RESULTS

The results showed that terminally ill cancer patients had a good quality of life. Last year, 85.7% of participants used at least one kind of CAM. Furthermore, 45.4% of participants used only one form of CAM, 30.3% used two types of CAM, 6.7% used three types of CAM, and 3.4% used four to five types of CAM. When all CAM users were compared to non-CAM users, CAM users had significantly higher social QOL and overall quality of life. Two subscales of QOL symptoms and function were correlated with cancer history, income, and use of CAMs, and the scores of QOL symptoms and function were greater in CAM users compared to non-CAM users. Among all the study variables, only the usage of CAM was correlated to overall QOL among terminally ill cancer patients.

CONCLUSION

The current study found that using CAM could affect different aspects of QOL in terminally ill cancer patients. As a result, it is feasible that using CAM could help these people enhance their health and QOL.

Research on Translation of Chinese Medicine Constitution (Tizhi) Academic Terms: Based on Memetics and Delphi Method

Background. With the continuous in-depth research of Chinese medicine constitution (tizhi) and the continuous expansion of cross research with new disciplines, internationalization will become the future trend of Chinese medicine constitution (tizhi). Translating the terms of Chinese medicine constitution (tizhi) into English is the first step for Chinese medicine constitution (tizhi) to go international. Language memes play an important role in information transmission in social interpersonal communication activities. The continuous replication and dissemination of translation memes make language spread and popularized. Because there is no fixed translation method at present, based on the particularity of Chinese medicine constitution (tizhi), we decided to use the Delphi method to complete the term translation research. Objective. The purpose of this study is to provide a standard and unified translation method for terms of traditional Chinese medicine (TCM) constitution with Chinese characteristics through the Delphi expert consultation strategy. Methods. Forward translation and expert consensus were conducted to complete this study. We sorted out the related terms of Chinese medicine constitution (tizhi) theory and invited an expert from the World Federation of Chinese Medicine Societies (WFCMS) to complete the initial forward translation. An expert of Chinese medicine constitution (tizhi) theory joined this process. Then, we invite relevant professionals to evaluate this translation version using the Delphi method. Results. Following a 3-round Delphi survey, the translation criteria of 61 (92.42%) terms were unified, and 5 terms resulted in no consensus and reached consensus on the translation method of Chinese medicine constitution (tizhi) theory. A major problem about how to translate “中医体质学” is identified. 25 experts participated in this study, and the drop-out rate is 0% in the 3-round Delphi survey. Translation challenges include the following: (1) translation methods of “Chinese medicine constitution (tizhi) theory”; (2) experts’ understanding deviation on the definitions of some terms. Conclusions. The average mode, full score ratio, standard deviation, coefficient of variation, and variation ratio of expert scores are analyzed. The diversity of regions and professional titles of experts shows that they have a high degree of authority. The scores of terms indicate the consistent of study results, so they can be used as a reference for the translation of Chinese medicine constitution (tizhi) theory.

Current Situation and Influencing Factors of Traditional Chinese Medicine Nursing Clinic in Henan Province

Objective

To explore the current situation and influencing factors of traditional Chinese medicine (TCM) nursing clinic in Henan Province. A self-made questionnaire was made and entered into the questionnaire star. In August 2020, through "the snowball sampling method," the nursing branch of Henan Society of Traditional Chinese Medicine was used to calculate the sample size that would be further used for this study.

Results

Of the 370 medical institutions in 17 district-level cities in our province, 47 have set up TCM nursing clinics, accounting for 12.70%. From the perspective of regional distribution, there are 14 TCM nursing clinics in Zhengzhou, 8 in Luoyang, 6 in Kaifeng, 4 in Shangqiu, 3 in Jiyuan, and 3 in Zhoukou. The number of TCM nursing clinics in Jiaozuo City, Xinxiang City, Anyang City, Hebi City, Puyang City, Zhumadian City, and Nanyang City is relatively small, and there are no TCM nursing clinics in Pingdingshan City, Sanmenxia City, and Xinyang City. Among the 47 medical institutions offering TCM nursing clinics, there are 38 TCM hospitals, 5 integrated traditional Chinese and Western medicine hospitals, 3 Western medicine hospitals, and 1 ethnic medicine hospital. Among them, 31 medical institutions are tertiary care hospitals and 16 are secondary care hospitals. First-class and undetermined medical institutions do not set up TCM nursing clinics. (1) Management mode: among the 47 medical institutions, 26 medical institutions have separate nursing units, which are managed by the nursing department head nurse, and 13 medical institutions are managed by the director head nurse of the department. (2) Performance management: of the 47 medical institutions that set up TCM nursing clinics, 18 adopted independent accounting, 21 adopted secondary distribution of departmental performance, and 7 adopted average awards and other methods. (3) The process of seeing a doctor: there are three kinds of medical procedures: 124 medical institutions are treated by TCM nursing outpatients by hanging the consultation number of doctors in various departments. 210 medical institutions are treated by traditional Chinese medicine nursing outpatient nurses by hanging the consultation number of traditional Chinese medicine nursing outpatient doctors. Thirty-five medical institutions are retreated by hanging the number of nurses in the nursing clinic of TCM. (4) Allocation of human resources: in the survey of the total number of nurses in TCM nursing clinics in 74 medical institutions, the largest number of nurses was 46 in one of the TCM nursing clinics. In terms of personnel qualification requirements, 43 medical institutions put forward requirements for nurses' qualifications. Among them, 39 medical institutions have requirements for nurses' professional titles, 38 medical institutions have requirements for nurses working years, and 22 medical institutions have more specific requirements for nurses. For example, nurses are required to be the backbone of TCM nursing that includes specialist nurses, nurses who graduated from TCM colleges, and nurses who have obtained hospital assessment and certification. In terms of working years, 87.96% of medical institutions require nursing service of more than 5 years. The average number of TCM nursing technical projects offered by 47 medical institutions is about 10, a maximum of 34 and a minimum of 1. The commonly carried out TCM nursing techniques include scraping, auricular point pressing, cupping, moxibustion, and ear tip bloodletting, and among all of them, scraping technology is most important and 40 medical institutions offer this technology, followed by auricular point pressing technique, cupping, and moxibustion.

Conclusion

The construction of TCM nursing clinics in Henan Province has initially formed a scale, and all kinds of medical institutions at all levels should further strengthen the construction of TCM nursing clinics in all other provinces.

Acupuncture combined with opioids for cancer pain: a pilot pragmatic randomized controlled trial

OBJECTIVE

Given the existing evidence for the analgesic effect of acupuncture, the current study aimed to assess whether acupuncture could be feasible and manageable as an adjunctive therapy for cancer pain in a real-world hospital setting.

METHODS

Thirty patients in an Oncology department with moderate or severe pain were recruited and randomized to an adjunctive acupuncture group or control group, who received pharmacotherapy for pain management without acupuncture. The duration of the treatment course was 1 week with a 2-week follow-up. In total, four acupuncture sessions were administered, on days 1/2/4/6 of the trial. Pain intensity was measured using a numerical rating scale (NRS) and the daily opioid dose was recorded.

RESULTS

The overall trends favored acupuncture for both pain intensity and daily opioid consumption. The proportion of participants experiencing at least a 2-point reduction in the NRS at the end of the treatment was 93% (n = 14/15) for the acupuncture group and 57% (n = 8/14) for the control group (risk difference (RD) 36.1%, 95% confidence interval (CI) [7.4%-65.0%]; relative risk (RR) 1.63, 95% CI [1.02-2.62]; p = 0.04). There were no serious adverse events and no dropouts during the treatment.

CONCLUSION

This pilot study showed that adding acupuncture to routine analgesia for patients with cancer pain was feasible and acceptable to patients. The clinical effects of adding acupuncture as an adjunctive therapy need to be further evaluated.

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR1800017023 (Chinese Clinical Trial Registry).

PRAgmatic Clinical Trial Design of Integrative MediCinE (PRACTICE): A Focus Group Series and Systematic Review on Trials of Diabetes and Kidney Disease

Background: Pragmatic trials inform clinical decision with better generalizability and can bridge different streams of medicine. This study collated the expectations regarding pragmatic trial design of integrative medicine (IM) for diabetes and kidney diseases among patients and physicians. Dissonance between users' perspective and existing pragmatic trial design was identified. The association between risk of bias and pragmatism of study design was assessed. Method: A 10-group semi-structured focus group interview series [21 patients, 14 conventional medicine (ConM) and 15 Chinese medicine (CM) physicians] were purposively sampled from private and public clinics in Hong Kong. Perspectives were qualitatively analyzed by constant comparative method. A systematic search of four databases was performed to identify existing IM pragmatic clinical trials in diabetes or kidney disease. Primary outcomes were the pragmatism, risk of bias, and rationale of the study design. Risk of bias and pragmatism were assessed based on Cochrane risk-of-bias tool and PRECIS-2, respectively. The correlation between risk of bias and pragmatism was assessed by regression models with sensitivity analyses. Results: The subtheme on the motivation to seek IM service was analyzed, covering the perceived limitation of ConM effect, perceived benefits of IM service, and assessment of IM effectiveness. Patients expected IM service to retard disease progression, stabilize concomitant drug dosage, and reduce potential side effects associated with ConM. In the systematic review, 25 studies from six countries were included covering CM, Korean medicine, Ayurvedic medicine, and western herbal medicine. Existing study designs did not include a detailed assessment of concomitant drug change and adverse events. Majority of studies either recruited a non-representative proportion of patients as traditional, complementary, and integrative medicine (TCIM) diagnosis was used as inclusion criteria, or not reflecting the real-world practice of TCIM by completely dropping TCIM diagnosis in the trial design. Consultation follow-up frequency is the least pragmatic domain. Increase in pragmatism did not associate with a higher risk of bias. Conclusion: Existing IM pragmatic trial design does not match the patients' expectation in the analysis of incident concomitant drug change and adverse events. A two-layer design incorporating TCIM diagnosis as a stratification factor maximizes the generalizability of evidence and real-world translation of both ConM and TCIM.

Prioritizing Chinese medicine clinical research questions in cancer palliative care from patient and caregiver perspectives

BACKGROUND

Chinese medicine (CM) modalities, including acupuncture and Chinese herbal medicine (CHM), are popular palliative interventions among patients with cancer, but further clinical research is required to assess their effectiveness and safety.

OBJECTIVE

To prioritize top ten important CM clinical research questions from patients with cancer, cancer survivors and caregivers' perspectives via a face-to-face prioritization workshop in Hong Kong.

METHODS

A list of 25 CM clinical research questions for cancer palliative care, which were identified from existing systematic reviews (SRs) and overview of SRs, was presented to 17 participants (patients with cancer [n = 5], cancer survivors [n = 6] and caregivers [n = 6]). The participants were then invited to establish consensus on prioritizing top ten research questions.

RESULTS

Among the top ten priorities, five (50%) focused on acupuncture and related therapies, while five (50%) were on CHM. The three most important research priorities were (i) manual acupuncture plus opioids for relieving pain; (ii) CHM for improving quality of life among patients receiving chemotherapy; and (iii) concurrent use of CHM plus loperamide for reducing stomatitis.

CONCLUSION

The top ten participant-endorsed CM clinical research priorities for cancer palliative care can guide local researchers on future direction. They can also inform local research funders on patient-centred allocation of limited funding. Under limited research funding, the most important co-prioritized research question from professional and patient perspectives may be addressed first.

PATIENT OR PUBLIC CONTRIBUTION

Patients with cancer, cancer survivors and caregivers participated in conduct of the study to prioritize CM clinical research questions.

Clinical Nurses Research Priorities in Hospital Settings: A Delphi Survey

This study aimed to identify the research priorities of clinical nurses to develop a research program at a health care services system that includes three hospitals. A Delphi survey was emailed to all clinical nurses in two rounds. The Delphi method was used to collect data from the nurses in regards to their priority research themes, and the data were analyzed using descriptive and comparative statistics. A total of 933 clinical nurses returned the first round of the Delphi survey and 543 nurses answered the second round. Clinical nurses identified 89 potential research themes. Patient safety and ethical challenges were the two highest ranked research priorities. The 40 highest ranked priority research themes were closely associated with issues concerning patient care and ethics. However, the nurses also gave high ratings to issues relating to the work environment, questions about technology implementation, and patient involvement in clinical care decisions.

Designing delivery models of traditional and complementary medicine services: a review of international experiences

BACKGROUND

The World Health Organization advocates integration of traditional and complementary medicine (T&CM) into the conventional health services delivery system. Integrating quality services in a patient-centred manner faces substantial challenges when T&CM is delivered within a health system dominated by conventional medicine. This review has synthesized international experiences of integration strategies across different contexts.

SOURCES OF DATA

Publications describing international experiences of delivering T&CM service in conventional healthcare settings were searched. Backward and forward citation chasing was also conducted.

AREAS OF AGREEMENT

Capable leaders are crucial in seeking endorsement from stakeholders within the conventional medicine hierarchy and regulatory bodies. However, patient demands for integrative care can be successful as demonstrated by cases included in this review, as can the promotion of the use of T&CM for filling effectiveness gaps in conventional medicine. Safeguarding quality and safety of the services is a priority.

AREAS OF CONTROVERSY

Different referral mechanisms between conventional and T&CM practitioners suit different contexts, but at a minimum, general guideline on responsibilities across the two professionals is required. Evidence-based condition-specific referral protocols with detailed integrative treatment planning are gaining in popularity.

GROWING POINTS

Interprofessional education is critical to establishing mutual trust and understanding between conventional clinicians and T&CM practitioners. Interprofessional communication is key to a successful collaboration, which can be strengthened by patient chart sharing, instant information exchange, and dedicated time for face-to-face interactions.

AREAS TIMELY FOR DEVELOPING RESEARCH

Research is needed on the optimal methods for financing integrated care to ensure equitable access, as well as in remuneration of T&CM practitioners working in integrative healthcare.

Acupuncture Therapy for Cognitive Impairment: A Delphi Expert Consensus Survey

Background

Current research evidence challenges clinical decision-making when acupuncture is taken into consideration in the treatment of cognitive impairment (CI). Aiming to provide some viable recommendations for acupuncture practitioners in dealing with actual clinic issues, an expert consensus study was conducted.

Methods

A clinical question investigation among 47 acupuncturists yielded 24 initial items. Subsequently, systematic reviews on acupuncture for CI were searched within three online databases. A panel of 30 authoritative experts were requested to respond with agreement, neutrality, or disagreement for each item. Consensus establishment was defined as the percentage of agreement on a given item >80%.

Results

Following a 2-round Delphi survey, there were 21 items reaching consensus and three items resulting in no consensus; of which 10 items reached 90∼100% agreement, and 80∼90% expert agreement was achieved for 11 items. These items could be roughly categorized into six domains: (1) therapeutic effects of acupuncture, (2) therapeutic principles, (3) acupoint selection and combination, (4) acupuncture parameters, (5) considerable combined therapies, and (6) possible adverse events.

Conclusion

Without ready-made guidelines, this expert consensus may be conducive to guide acupuncturists in implementing clinical acupuncture practice for CI. Moreover, given the lack of high-quality research evidence and plenty of unresolved clinical issues in this field, it is of necessity to carry out more studies to better clarify the treatment algorithm.