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Chew LJ, Urman DS, Maxwell K, Ajmera A, Millard F, McKay RR. Virtual Follow-Up in Patients Initiating Antineoplastic Treatment in the Ambulatory Setting. JCO Oncol Pract 2024:OP2300777. [PMID: 38457760 DOI: 10.1200/op.23.00777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/13/2024] [Accepted: 02/08/2024] [Indexed: 03/10/2024] Open
Abstract
PURPOSE Initiating antineoplastic therapy can be distressful and affect patient retention of treatment-related side effects and safety protocols. Return visits can range from 8 to 28 days after treatment, during which patients may develop treatment-related questions and toxicities. This study's objective is to evaluate how implementing a follow-up phone call 24-48 hours after initial antineoplastic infusion, compared with standard pretreatment education, affects patient satisfaction and education retention. METHODS We conducted a single-center pilot study where patients who were literate, English-speaking, with genitourinary malignancies, initiating intravenous chemotherapy or immunotherapy were eligible. The primary end point was patient knowledge retention. Secondary end points included patient satisfaction. The Leuven's Questionnaire Patient Knowledge Tool, a validated, standardized tool, was used to evaluate patient knowledge retention, with a higher score indicating more retention. Telephone follow-up was initiated 24-48 hours after initial infusion, where Leuven's Questionnaire was used to assess patient knowledge. A nurse then reinforced treatment-related education, reviewed notification parameters, and coordinated appropriate follow-up. One week later, participants were sent a follow-up Leuven's Questionnaire and standardized patient satisfaction assessment. RESULTS Thirty-one patients with renal cell carcinoma, prostate, bladder, germ cell/testicular, or adrenal cancers were included in the study. Mean preintervention Leuven's Questionnaire score was 5.3 and mean postintervention score was 8.1 on a 1-10 scale (P < .0001). Ninety-seven percent of patients reported improved satisfaction postintervention. CONCLUSION Proactive telephonic follow-up for oncology patients improves education retention, patient satisfaction, and has potential to improve patient safety and quality of care.
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Affiliation(s)
| | | | | | | | | | - Rana R McKay
- University of California San Diego, La Jolla, CA
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Chae S, Street WN, Ramaraju N, Gilbertson-White S. Prediction of Cancer Symptom Trajectory Using Longitudinal Electronic Health Record Data and Long Short-Term Memory Neural Network. JCO Clin Cancer Inform 2024; 8:e2300039. [PMID: 38471054 PMCID: PMC10948138 DOI: 10.1200/cci.23.00039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 12/08/2023] [Accepted: 01/26/2024] [Indexed: 03/14/2024] Open
Abstract
PURPOSE Ability to predict symptom severity and progression across treatment trajectories would allow clinicians to provide timely intervention and treatment planning. However, such predictions are difficult because of sparse and inconsistent assessment, and simplistic measures such as the last observed symptom severity are often used. The purpose of this study is to develop a model for predicting future cancer symptom experiences on the basis of past symptom experiences. PATIENTS AND METHODS We performed a retrospective, longitudinal analysis using records of patients with cancer (n = 208) hospitalized between 2008 and 2014. A long short-term memory (LSTM)-based recurrent neural network, a linear regression, and random forest models were trained on previous symptoms experienced and used to predict future symptom trajectories. RESULTS We found that at least one of three tested models (LSTM, linear regression, and random forest) outperform predictions based solely on the previous clinical observation. LSTM models significantly outperformed linear regression and random forest models in predicting nausea (P < .1) and psychosocial status (P < .01). Linear regression outperformed all models when predicting oral health (P < .01), while random forest outperformed all models when predicting mobility (P < .01) and nutrition (P < .01). CONCLUSION We can successfully predict patients' symptom trajectories with a prediction model, built with sparse assessment data, using routinely collected nursing documentation. The results of this project can be applied to better individualize symptom management to support cancer patients' quality of life.
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Affiliation(s)
- Sena Chae
- The University of Iowa College of Nursing, Iowa City, IA
| | - W. Nick Street
- The University of Iowa Tippie College of Business, Iowa City, IA
| | - Naveenkumar Ramaraju
- University of Illinois Urbana-Champaign, Gies College of Business, Champaign, IL
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3
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Ford S, Vaughn J, Subramaniam A, Gundala A, Hensley E, Shah N. Supporting data driven translational patient-centered care using network analysis to visualize symptom distress in children with serious illness. J SPEC PEDIATR NURS 2024; 29:e12422. [PMID: 38284219 DOI: 10.1111/jspn.12422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/21/2023] [Accepted: 01/02/2024] [Indexed: 01/30/2024]
Abstract
PURPOSE There are an increasing number of techniques and tools to improve the capacity for children to relay their perceptions of their symptom experience while undergoing blood and marrow transplant (BMT). Network analysis (NA) is a tool that can illustrate associations between symptoms and the distress they cause. We aimed to develop a biopsychosocial assessment clinical analytic tool to examine symptom relationships for children undergoing BMT to find actionable relationships for intervention to improve clinical outcomes including mood. DESIGN AND METHODS This pilot study used an analytical mobile application tool to support a wide scope of 15 biopsychosocial symptom distress levels and five mood assessments. Children recorded their symptom distress and mood using the app. NA was used to explore relationships between symptom distress and mood. RESULTS Four children, 11-14 years old, undergoing BMT used the app daily during hospitalization. We found a strong presence of emotional distress and its associations symptom distress and mood. Multiple symptom associations were identified including associations between the set of symptoms difficulty breathing and fever (0.557), sad and worried (0.429). Of note, pain distress had a strong capacity to bridge other symptoms and was connected directly to many symptoms. PRACTICE IMPLICATIONS We found the significance of patient struggles with emotional and symptom distress and the importance of this relationship to other clinical outcomes. This provides valuable insights and an improved understanding of the child's symptoms. Our findings support early assessment, intervention, and improved symptom communication to enhance sense of well-being and the child's care experience.
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Affiliation(s)
- Shannon Ford
- School of Nursing, College of Health and Human Services, University of North Carolina Wilmington, Wilmington, North Carolina, USA
| | - Jacqueline Vaughn
- School of Nursing, College of Health and Human Services, University of North Carolina Wilmington, Wilmington, North Carolina, USA
| | - Arvind Subramaniam
- East Carolina University Brody School of Medicine, Greenville, North Carolina, USA
| | - Abhinav Gundala
- North Carolina State University, Raleigh, North Carolina, USA
| | - Elizabeth Hensley
- University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nirmish Shah
- Duke University Medical Center, Durham, North Carolina, USA
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4
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Fleshner L, Lagree A, Shiner A, Alera MA, Bielecki M, Grant R, Kiss A, Krzyzanowska MK, Cheng I, Tran WT, Gandhi S. Drivers of Emergency Department Use Among Oncology Patients in the Era of Novel Cancer Therapeutics: A Systematic Review. Oncologist 2023; 28:1020-1033. [PMID: 37302801 PMCID: PMC10712716 DOI: 10.1093/oncolo/oyad161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/04/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND Patients diagnosed with cancer are frequent users of the emergency department (ED). While many visits are unavoidable, a significant portion may be potentially preventable ED visits (PPEDs). Cancer treatments have greatly advanced, whereby patients may present with unique toxicities from targeted therapies and are often living longer with advanced disease. Prior work focused on patients undergoing cytotoxic chemotherapy, and often excluded those on supportive care alone. Other contributors to ED visits in oncology, such as patient-level variables, are less well-established. Finally, prior studies focused on ED diagnoses to describe trends and did not evaluate PPEDs. An updated systematic review was completed to focus on PPEDs, novel cancer therapies, and patient-level variables, including those on supportive care alone. METHODS Three online databases were used. Included publications were in English, from 2012-2022, with sample sizes of ≥50, and reported predictors of ED presentation or ED diagnoses in oncology. RESULTS 45 studies were included. Six studies highlighted PPEDs with variable definitions. Common reasons for ED visits included pain (66%) or chemotherapy toxicities (69.1%). PPEDs were most frequent amongst breast cancer patients (13.4%) or patients receiving cytotoxic chemotherapy (20%). Three manuscripts included immunotherapy agents, and only one focused on end-of-life patients. CONCLUSION This updated systematic review highlights variability in oncology ED visits during the last decade. There is limited work on the concept of PPEDs, patient-level variables and patients on supportive care alone. Overall, pain and chemotherapy toxicities remain key drivers of ED visits in cancer patients. Further work is needed in this realm.
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Affiliation(s)
- Lauren Fleshner
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Andrew Lagree
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, Canada
- Temerty Centre for AI Research and Education, University of Toronto, Toronto, Canada
| | - Audrey Shiner
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Marie Angeli Alera
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Mateusz Bielecki
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Robert Grant
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Alex Kiss
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Monika K Krzyzanowska
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada
- The Cancer Quality Lab, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Ivy Cheng
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Emergency Medicine, University of Toronto, Toronto, Canada
| | - William T Tran
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Radiogenomics Laboratory, Sunnybrook Health Sciences Centre, Toronto, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
- Temerty Centre for AI Research and Education, University of Toronto, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Sonal Gandhi
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada
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5
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Deng Y, Hu H, Jia R, Dai W, Wang D, Zhang P, Zhang P, Cheng K, Tang J, Wen Y, Zhou X, Shi Q, Xiong Z, Zhou J. Patient-reported outcome (PRO)-based symptom assessment in patients with advanced lung cancer receiving first-line combination immunotherapy: a protocol for a multicenter, prospective, observational study. BMC Pulm Med 2023; 23:176. [PMID: 37208661 DOI: 10.1186/s12890-023-02432-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/13/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Immunotherapy is currently applied in the first-line treatment regimens for numerous advanced cancers, especially advanced lung cancer. Immune-related adverse events (irAEs) resulting from immunotherapy can vary in severity and cause a substantial symptom burden to patients. However, there are limited data on symptom burden in patients with advanced lung cancer following immunotherapy. To address this deficit, this study aims to provide insight into the symptom burden and severity through patient-reported outcome measurements and conduct an analysis of temporal trends and clinical consequences of symptom burden in patients with advanced lung cancer receiving combination immunotherapy. METHODS We will prospectively recruit 168 eligible patients from 14 hospitals in China. Eligible patients will be aged ≥ 18 years, pathologically diagnosed with locally advanced or stage IV primary lung cancer without surgical indications, and agreed to receive immunotherapy in combination with other therapies. The primary outcome of this study is the symptom burden of patients during the immunotherapy course. Longitudinal symptom data will be collected using the MD Anderson Symptom Inventory-Lung Cancer module (MDASI-LC) and the symptomatic irAEs scale at baseline (once before treatment) and weekly after treatment, until 1 month after the last treatment cycle has been completed. The trajectory of symptom burden following combination immunotherapy will be depicted, and by linking it to clinical outcomes (the secondary outcome and exploratory outcome of this study), the consequence of symptom burden in patients with advanced lung cancer receiving combination immunotherapy will be examined further. DISCUSSION This study intends to establish longitudinal symptom trajectories in patients with lung cancer receiving immunotherapy, and explore its association with clinical outcomes. These findings may serve as an important reference for clinicians in the symptomatic management of patients with lung cancer receiving immunotherapy. TRIAL REGISTRATION NUMBER ChiCTR2200061540. Registered on June 28, 2022.
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Affiliation(s)
- Yuanle Deng
- Department of Clinical Nutrition, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Han Hu
- Department of Clinical Nutrition, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Rong Jia
- Department of Medical Oncology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Wei Dai
- Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Dengfeng Wang
- Gynecologic Oncology Center, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Purong Zhang
- Department of Breast Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Peng Zhang
- Department of Radiation Oncology, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Kai Cheng
- Department of Pharmacy, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Jianning Tang
- Department of Medical Oncology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Yan Wen
- Department of Medical Oncology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Xiang Zhou
- Department of Gastrointestinal Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Qiuling Shi
- Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
- School of Public Health, Chongqing Medical University, Chongqing, China
| | - Zhujuan Xiong
- Department of Clinical Nutrition, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China.
| | - Jin Zhou
- Department of Medical Oncology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China.
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6
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Feng LN, He J, Feng LX, Li Y, Li J, Chen C. Symptoms, symptom clusters and associated factors among cancer patients receiving immune checkpoint inhibitor therapy: A cross-sectional survey. Eur J Oncol Nurs 2023; 63:102288. [PMID: 36893574 DOI: 10.1016/j.ejon.2023.102288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 01/18/2023] [Accepted: 02/10/2023] [Indexed: 02/12/2023]
Abstract
PURPOSE The purpose of this study was to explore the symptoms and symptom clusters and analyse associated factors among cancer patients receiving ICI therapy. METHODS We analysed the data of 216 cancer patients who received immune checkpoint inhibitor therapy from the internal medicine unit of a university cancer centre in China. Participants were surveyed using the Eastern Cooperative Oncology Group Performance Score (ECOG PS) assessment, the ICI therapy symptom assessment scale, and demographic and disease characteristic questionnaires designed for this study. Exploratory factor analysis and multiple linear regression analysis were performed to analyse the data. RESULTS The most common symptoms in patients with grade 1-2 symptom severity were fatigue (57.4%), itching (34.3%) and cough (33.3%), and those with grade 3-4 symptom severity were rash (7.9%), joint pain (6.9%), muscle soreness (6.5%) and fatigue (6.5%). Four symptom clusters were identified: nonspecific, musculoskeletal, respiratory and cutaneous (the cumulative contribution to the variance was 64.070%). ECOG PS, disease course and gender were significantly associated with the nonspecific symptom cluster (Adj R2 = 14.3). ECOG PS and disease course were significantly associated with the respiratory symptom cluster (Adj R2 = 8.9). ECOG PS, disease course and education level were significantly associated with the musculoskeletal symptom cluster (Adj R2 = 20.2). CONCLUSION Cancer patients receiving ICI therapy experience various symptoms with apparent clustering. The factors associated with symptom clusters included gender, education level, ECOG PS and disease course. These findings would be useful for medical personnel to provide relevant interventions to promote symptom management of ICI therapy.
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Affiliation(s)
- Li Na Feng
- Department of Lymphoma, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Jin He
- Department of Lymphoma, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China.
| | - Li Xia Feng
- Nursing Department, Tianjin Cancer Hospital Airport Hospital, Tianjin, China
| | - Yan Li
- Department of Gastrointestinal Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Juan Li
- Department of Lymphoma, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Chen Chen
- Department of Lymphoma, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
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7
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Daly B, Nicholas KJ, Flynn J, Panageas KS, Silva N, Duck E, Zervoudakis A, Holland J, Salvaggio R, Begue A, Wagner I, Sokolowski S, Zablocki M, Chiu YO, Kuperman GJ, Simon BA, Perchick W, Reidy‐Lagunes DL. Association Between Remote Monitoring and Acute Care Visits in High-Risk Patients Initiating Intravenous Antineoplastic Therapy. JCO Oncol Pract 2022; 18:e1935-e1942. [PMID: 36265089 PMCID: PMC9750548 DOI: 10.1200/op.22.00294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/26/2022] [Accepted: 08/20/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Traditional oncology care models have not effectively identified and managed at-risk patients to prevent acute care. A next step is to harness advances in technology to enable patients to report symptoms any time, enabling digital hovering-intensive symptom monitoring and management. Our objective was to evaluate a digital platform that identifies and remotely monitors high-risk patients initiating antineoplastic therapy with the goal of preventing acute care visits. METHODS This was a single-institution matched cohort quality improvement study conducted at a National Cancer Institute-designated cancer center between January 1, 2019, and March 31, 2020. Eligible patients were those initiating intravenous antineoplastic therapy who were identified as high risk for seeking acute care. Enrolled patients' symptoms were monitored using a digital platform. A dedicated team of clinicians managed reported symptoms. The primary outcomes of emergency department visits and hospitalizations within 6 months of treatment initiation were analyzed using cumulative incidence analyses with a competing risk of death. RESULTS Eighty-one patients from the intervention arm were matched by stage and disease with contemporaneous high-risk control patients. The matched cohort had similar baseline characteristics. The cumulative incidence of an emergency department visit for the intervention cohort was 0.27 (95% CI, 0.17 to 0.37) at six months compared with 0.47 (95% CI, 0.36 to 0.58) in the control (P = .01) and of an inpatient admission was 0.23 (95% CI, 0.14 to 0.33) in the intervention cohort versus 0.41 (95% CI, 0.30 to 0.51) in the control (P = .02). CONCLUSION The narrow employment of technology solutions to complex care delivery challenges in oncology can improve outcomes and innovate care. This program was a first step in using a digital platform and a remote team to improve symptom care for high-risk patients.
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Affiliation(s)
- Bobby Daly
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Jessica Flynn
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Elaine Duck
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Aaron Begue
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Isaac Wagner
- Memorial Sloan Kettering Cancer Center, New York, NY
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8
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Scordo M, Shah GL, Adintori PA, Knezevic A, Devlin SM, Buchan ML, Preston EV, Lin AP, Rodriguez NT, Carino CA, Nguyen LK, Sitner NC, Barasch A, Klang MG, Maloy MA, Mastrogiacomo B, Carlow DC, Schofield RC, Slingerland AE, Slingerland JB, Stein-Thoeringer CK, Lahoud OB, Landau HJ, Chung DJ, van den Brink MRM, Peled JU, Giralt SA. A prospective study of dysgeusia and related symptoms in patients with multiple myeloma after autologous hematopoietic cell transplantation. Cancer 2022; 128:3850-3859. [PMID: 36041227 PMCID: PMC10010839 DOI: 10.1002/cncr.34444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/17/2022] [Accepted: 06/06/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND Dysgeusia is a common but understudied complication in patients undergoing autologous hematopoietic cell transplantation (auto-HCT). We assessed the feasibility of using chemical gustometry (CG) to measure dysgeusia and explored its associations with symptom burden, nutrition, chemotherapy pharmacokinetics (PK), and the oral microbiome. METHODS We conducted a single-center, prospective feasibility study (NCT03276481) of patients with multiple myeloma undergoing auto-HCT. CG was performed longitudinally testing five flavors (sweet, sour, salty, bitter, umami) to calculate a total taste score (maximum score, 30). We measured caloric intake and patient-reported symptoms, assessing their correlation with oral microbiota composition and salivary and blood melphalan PK exposure. RESULTS Among all 45 patients, 39 (87%) completed at least four (>60%) and 22 (49%) completed all six CG assessments. Median total CG scores remained stable over time but were lowest at day +7 (27, range 24-30) with recovery by day +100. Symptom burden was highest by day +10 (area under the curve, 2.9; range, 1.0-4.6) corresponding with the lowest median overall caloric intake (1624 kcal; range, 1345-2267). Higher serum/salivary melphalan levels correlated with higher patient-reported dysgeusia and lower caloric intake. Oral microbiota α-diversity was stable early and increased slightly by day +100. CONCLUSIONS Assessment of dysgeusia by CG is feasible after auto-HCT. Most dysgeusia, symptom burden, and lowest caloric intake occurred during the blood count nadir. Higher melphalan concentrations correlated with more dysgeusia and poorer caloric intake. Future studies will aim to modulate melphalan exposure by PK-targeted dosing and characterize patient taste preferences to personalize diets for improved nutritional intake. LAY SUMMARY Taste changes after cancer treatments are very common. We used chemical gustometry (taste testing) to study taste changes and to better understand why patients with multiple myeloma experience this symptom after autologous hematopoietic cell transplantation. We found that taste testing was feasible, taste changes peaked when blood counts were lowest, and most patients recovered their taste by 100 days after transplantation. Taste changes correlated with lower food intake and with higher levels of chemotherapy in the body. Future work will focus on using personalized chemotherapy doses to reduce taste changes and to match patients' individual taste preferences with their diets.
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Affiliation(s)
- Michael Scordo
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Gunjan L Shah
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Peter A Adintori
- Food and Nutrition Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andrea Knezevic
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sean M Devlin
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Elaina V Preston
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andrew P Lin
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Natasia T Rodriguez
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Caroline A Carino
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Linh K Nguyen
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Nancy Cruz Sitner
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andrei Barasch
- Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, Massachusetts, USA
| | - Mark G Klang
- Research Pharmacy, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Molly A Maloy
- Department of Health Informatics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Brooke Mastrogiacomo
- Human Oncology and Pathogenesis Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Dean C Carlow
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ryan C Schofield
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ann E Slingerland
- Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - John B Slingerland
- Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Oscar B Lahoud
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Heather J Landau
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - David J Chung
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Marcel R M van den Brink
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Jonathan U Peled
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Sergio A Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
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9
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Offodile AC, DiBrito SR, Finder JP, Shete S, Jain S, Delgado DA, Miller CJ, Davidson E, Overman MJ, Peterson SK. Active surveillance of chemotherapy-related symptom burden in ambulatory cancer patients via the implementation of electronic patient-reported outcomes and sensor-enabled vital signs capture: protocol for a decentralised feasibility pilot study. BMJ Open 2022; 12:e057693. [PMID: 35383081 PMCID: PMC8984061 DOI: 10.1136/bmjopen-2021-057693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Remote patient monitoring (RPM) has emerged as a potential avenue for optimising the management of symptoms in patients undergoing chemotherapy. However, RPM is a complex, multilevel intervention with technology, workflow, contextual and patient experience components. The purpose of this pilot study is to determine the feasibility of RPM protocol implementation with respect to decentralised recruitment, patient retention, adherence to reporting recommendations, RPM platform usability and patient experience in ambulatory cancer patients at high risk for chemotherapy-related symptoms. METHODS AND ANALYSIS This protocol describes a single-arm decentralised feasibility pilot study of technology-enhanced outpatient symptom management system in patients with gastrointestinal and thoracic cancer receiving chemotherapy and cancer care at a single site (MD Anderson Cancer Center, Houston Texas). An anticipated total of 25 patients will be recruited prior to the initiation of chemotherapy and provided with a set of validated questionnaires at enrollment and after our 1-month feasibility pilot trial period. Our intervention entails the self-reporting of symptoms and vital signs via a HIPAA-compliant, secure tablet interface that also enables (1) the provision of self-care materials to patients, (2) generation of threshold alerts to a dedicated call-centre and (3) videoconferencing. Vital sign information (heart rate, blood pressure, pulse, oxygen saturation, weight and temperature) will be captured via Bluetooth-enabled biometric monitoring devices which are integrated with the tablet interface. Protocolised triage and management of symptoms will occur in response to the alerts. Feasibility and acceptability metrics will characterise our recruitment process, protocol adherence, patient retention and usability of the RPM platform. We will also document the perceived effectiveness of our intervention by patients. ETHICS AND DISSEMINATION This study has been granted approval by the institutional review board of MD Anderson Cancer Center. We anticipate dissemination of our pilot and subsequent effectiveness trial results via presentations at national conferences and peer-reviewed publications in the relevant medical journals. Our results will also be made available to cancer survivors, their caregivers and hospital administration. TRIAL REGISTRATION NUMBER NCI202107464.
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Affiliation(s)
- Anaeze C Offodile
- Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sandra R DiBrito
- Division of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Janice P Finder
- Patient Experience Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sanjay Shete
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sanchita Jain
- Office of the Chief, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Domenica A Delgado
- Office of the Chief, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Christopher J Miller
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elenita Davidson
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael J Overman
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Susan K Peterson
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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10
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Zhang L, Zhang X, Shen L, Zhu D, Ma S, Cong L. Efficiency of Electronic Health Record Assessment of Patient-Reported Outcomes After Cancer Immunotherapy: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e224427. [PMID: 35357459 PMCID: PMC8972037 DOI: 10.1001/jamanetworkopen.2022.4427] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Cancer immunotherapy causes a wide range of immune-related adverse events (irAEs) that require close and timely follow-up. OBJECTIVES To compare the efficiency between electronic patient-reported outcomes (ePRO) and traditional follow-up models in cancer immunotherapy. DESIGN, SETTING, AND PARTICIPANTS This open-label randomized clinical trial was performed from September 1, 2019, to March 31, 2021. Patients were randomized to the ePRO model intervention or a control group by a computer system. A total of 28 Chinese tertiary care hospitals participated. Patients who were receiving cancer immunotherapy and could use smartphones or computers were eligible. A total of 300 patients were screened and 278 (92.7%) were enrolled. INTERVENTIONS The control group was followed up using traditional methods, including clinic visits every 21 days and telephone follow-up every 3 months. In the intervention group, the ePRO follow-up model included a questionnaire of common symptoms and an image recognition function to evaluate grades of typical irAEs. Patients completed questionnaires weekly and uploaded pictures of results between visits. When grade 1 or 2 irAEs occurred, standardized advice was sent automatically. If grade 3 or 4 irAEs were reported, the model alerted the health care team for assessment and intervention immediately. All patients were followed up for 6 months or until treatment completion. MAIN OUTCOMES AND MEASURES Incidence of serious (grades 3 to 4) irAEs, emergency department (ED) visits, quality of life (QOL), time spent implementing the ePRO model, rate of treatment discontinuation, and death were compared between groups post intervention. RESULTS A total of 278 patients (mean [SD] age, 58.8 [12.7 (range, 27-78)] years; 206 men [74.1%]) were included in the analysis, consisting of 141 in the intervention group and 137 in the control group. At the postintervention evaluation, the intervention group showed a reduced incidence of serious irAEs (29 of 141 [20.6%] vs 46 of 137 [33.6%]; hazard ratio [HR], 0.51 [95% CI, 0.30-0.88]; P = .01), fewer ED visits (23 of 141 [16.3%] vs 41 of 137 [29.9%]; HR, 0.46 [95% CI, 0.26-0.81]; P = .01), a lower rate of treatment discontinuation (5 of 141 [3.6%] vs 15 of 137 [11.0%]; HR, 0.30 [95% CI, 0.11-0.85]; P = .02), a higher QOL level (mean [SD] score, 74.2 [15.1; 95% CI, 71.7-76.9] vs 64.7 [28.5; 95% CI, 61.0-68.4]; P = .001), and less time implementing follow-up (mean [SD], 8.2 [3.9; 95% CI, 5.0-10.6] minutes vs 36.1 [15.3; 95% CI, 33.6-38.8] minutes; P < .001). However, there were no significant differences between groups in death rates (2 of 141 [1.4%] vs 5 of 137 [3.6%]; HR, 0.38 [95% CI, 0.07-1.99]; P = .28). CONCLUSIONS AND RELEVANCE This randomized clinical trial found that the ePRO follow-up model can improve safety and QOL of patients receiving cancer immunotherapy as well as reduce time spent monitoring. This model may provide reliable information and management recommendations. TRIAL REGISTRATION Chinese Clinical Trial Registry Identifier: ChiCTR2100052819.
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Affiliation(s)
- Liyan Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of GI Medical Oncology, Peking University School of Oncology, Beijing Cancer Hospital & Institute, Beijing, China
| | - Xiaotian Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of GI Medical Oncology, Peking University School of Oncology, Beijing Cancer Hospital & Institute, Beijing, China
| | - Lin Shen
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of GI Medical Oncology, Peking University School of Oncology, Beijing Cancer Hospital & Institute, Beijing, China
| | - Dan Zhu
- Aistarfish Technology Co, Ltd, Zhejiang, China
| | - Saili Ma
- Aistarfish Technology Co, Ltd, Zhejiang, China
| | - Lin Cong
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of GI Medical Oncology, Peking University School of Oncology, Beijing Cancer Hospital & Institute, Beijing, China
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11
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Daly B, Nicholas K, Flynn J, Silva N, Panageas K, Mao JJ, Gazit L, Gorenshteyn D, Sokolowski S, Newman T, Perry C, Wagner I, Zervoudakis A, Salvaggio R, Holland J, Chiu YO, Kuperman GJ, Simon BA, Reidy-Lagunes DL, Perchick W. Analysis of a Remote Monitoring Program for Symptoms Among Adults With Cancer Receiving Antineoplastic Therapy. JAMA Netw Open 2022; 5:e221078. [PMID: 35244701 PMCID: PMC8897754 DOI: 10.1001/jamanetworkopen.2022.1078] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
IMPORTANCE Electronic patient-reported outcomes (ePROs) may have the potential to improve cancer care delivery by enhancing patient quality of life, reducing acute care visits, and extending overall survival. However, the optimal cadence of ePRO assessments is unknown. OBJECTIVE To determine patient response preferences and the clinical value associated with a daily cadence for ePROs for patients receiving antineoplastic treatment. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study of adult patients undergoing antineoplastic treatment assessed a remote monitoring program using ePROs that was developed to manage cancer therapy-related symptoms. ePRO data submitted between October 16, 2018 to February 29, 2020, from a single regional site within the Memorial Sloan Kettering Cancer Center network were included. Data were analyzed from April 2020 to January 2022. EXPOSURE While undergoing active treatment, patients received a daily ePRO assessment that, based on patient responses, generated yellow (moderate) or red (severe) symptom alerts that were sent to clinicians. MAIN OUTCOMES AND MEASURES The main outcomes assessed included patient response rate, symptom alert frequency, and an analysis of the clinical value of daily ePROs. RESULTS A total of 217 patients (median [range] age, 66 [31-92] years; 103 [47.5%] women and 114 [52.5%] men) initiating antineoplastic therapy at high risk for symptoms were monitored for a median (range) of 91 (2-369) days. Most patients had thoracic (59 patients [27.2%]), head and neck (48 patients [22.1%]), or gastrointestinal (43 patients [19.8%]) malignant neoplasms. Of 14 603 unique symptom assessments completed, 7349 (50.3%) generated red or yellow symptom alerts. Symptoms commonly generating alerts included pain (665 assessments [23.0%]) and functional status (465 assessments [16.1%]). Most assessments (8438 assessments [57.8%]) were completed at home during regular clinic hours (ie, 9 am-5 pm), with higher response rates on weekdays (58.4%; 95% CI, 57.5%-59.5%) than on weekend days (51.3%; 95% CI, 49.5%-53.1%). Importantly, 284 of 630 unique red alerts (45.1%) surfaced without a prior yellow alert for the same symptom within the prior 7 days; symptom severity fluctuated over the course of a week, and symptom assessments generating a red alert were followed by an acute care visit within 7 days 8.7% of the time compared with 2.9% for assessments without a red alert. CONCLUSIONS AND RELEVANCE These findings suggest that daily ePRO assessments were associated with increased insight into symptom management in patients undergoing antineoplastic treatment and symptom alerts were associated with risk of acute care.
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Affiliation(s)
- Bobby Daly
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kevin Nicholas
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jessica Flynn
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nicholas Silva
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Jun J. Mao
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lior Gazit
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | - Claire Perry
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Isaac Wagner
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Rori Salvaggio
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jessie Holland
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yeneat O. Chiu
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Brett A. Simon
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Wendy Perchick
- Memorial Sloan Kettering Cancer Center, New York, New York
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12
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Zhang L, Lu Y. Follow-up Care for Patients Receiving Immune Checkpoint Inhibitors. Asia Pac J Oncol Nurs 2021; 8:596-603. [PMID: 34790843 PMCID: PMC8522586 DOI: 10.4103/apjon.apjon-2129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/27/2021] [Indexed: 12/19/2022] Open
Abstract
The rapid advances in cancer immunotherapy using immune checkpoint inhibitors (ICIs) have led to significantly improved survival of patients. But at the same time, it also associates with multiple immune-related adverse events (irAEs). The irAEs can affect a wide range of organs, and induce nonspecific symptoms with delayed onset and prolonged duration that is easily neglected, which may lead to life-threatening disorders. Therefore, follow-up care for patients receiving ICIs for irAEs management has become an essential competency in cancer nursing. There are several guidelines about the management of irAEs, which focused on diagnosis, grading, and treatment. However, studies on relevant follow-up care are rare. Nurses play an important role in follow-up care, whose relevant knowledge and skills are indispensable. Combined with domestic and foreign guidelines and related studies, this paper reviewed the occurrence and characteristics of irAEs and highlighted the contents, timing, models, and effects of follow-up care for patients receiving ICIs, to provide a reference for clinical nursing practice and improve the safety of immunotherapy for patients.
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Affiliation(s)
- Liyan Zhang
- Department of GI Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Beijing, China
| | - Yuhan Lu
- Department of Nursing, Peking University Cancer Hospital and Institute, Beijing, China
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13
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Gould Rothberg BE, Canavan ME, Mun S, Sedghi T, Carafeno T, Raucci M, Dest V, Sinanis N, Gross CP, Adelson KB. Impact of a Dedicated Cancer Urgent Care Center on Acute Care Utilization. JCO Oncol Pract 2021; 18:e129-e136. [PMID: 34383579 DOI: 10.1200/op.21.00183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Acute care imposes a significant burden on patients and cancer care costs. We examined whether an advanced practice provider-driven, cancer-specific urgent care center embedded within a large tertiary academic center decreased acute care use among oncology patients on active therapy. MATERIALS AND METHODS We conducted a quasi-experimental study anchored around the Oncology Extended Care Clinic (OECC) opening date. We evaluated two parallel 4-month periods: a post-OECC period that followed a 5-month run-in phase, and the identical calendar period 1 year earlier. Our primary outcomes included all emergency department (ED) presentations and hospital admissions during the 3-month window following the index provider visit. We used Poisson models to calculate absolute pre-OECC v post-OECC rate differences. RESULTS Our cohort included 2,095 patients in the pre-OECC period and 2,188 in the post-OECC period. We identified 32.6 ED visits/100 patients and 41.2 hospitalizations/100 patients in the pre-OECC period, versus 28.2 ED visits/100 patients and 26.1 hospitalizations/100 patients post-OECC. After adjusting for age, sex, race and ethnicity, and practice location, we observed a significant decrease of 4.6 ED visits/100 patients during the post-OECC period (95% CI, -8.92/100 to -0.28/100; P = .04) compared with the pre-OECC period. There was no significant association between the OECC opening and hospitalization rate (rate difference: -3.29 admissions/100 patients; 95% CI, -8.24/100 to 1.67/100; P = .19). CONCLUSION Establishing a cancer-specific urgent care center was significantly associated with a modest decrease in emergency room utilization but not with hospitalization rate. Barriers included clinic capacity, patient awareness, and physician comfort with advanced practice provider autonomy. Optimizing workflow and standardizing clinical pathways can create benchmarks useful for value-based payments.
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Affiliation(s)
| | - Maureen E Canavan
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT.,Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Sophia Mun
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT
| | - Tannaz Sedghi
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT
| | - Tracy Carafeno
- Smilow Cancer Hospital at Yale-New Haven Health, New Haven, CT
| | - Maureen Raucci
- Smilow Cancer Hospital at Yale-New Haven Health, New Haven, CT
| | - Vanna Dest
- Smilow Cancer Hospital at Yale-New Haven Health, New Haven, CT
| | - Naralys Sinanis
- Smilow Cancer Hospital at Yale-New Haven Health, New Haven, CT
| | - Cary P Gross
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT.,Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Kerin B Adelson
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT.,Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
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14
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Daly B, Lauria TS, Holland JC, Garcia J, Majeed J, Walters CB, Zablocki M, Chow K, Strachna O, Giles CE, Kelly MF, Housen A, Canavan M, Maresca NM, Baser R, Salvaggio R, Robson ME, Reidy-Lagunes DL. Oncology Patients' Perspectives on Remote Patient Monitoring for COVID-19. JCO Oncol Pract 2021; 17:e1278-e1285. [PMID: 34085536 DOI: 10.1200/op.21.00269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Oncology patients are vulnerable to adverse outcomes associated with COVID-19, and clinical deterioration must be identified early. Several institutions launched remote patient monitoring programs (RPMPs) to care for patients with COVID-19. We describe patients' perspectives on a COVID-19 RPMP at a National Comprehensive Cancer Center. METHODS Patients who tested positive for COVID-19 were eligible. Enrolled patients received a daily electronic COVID-19 symptom assessment, and a subset of high-risk patients also received a pulse oximeter. Monitoring was provided by a centralized team and was discontinued 14 days after a patient's positive test result and following 3 days without worsening symptoms. Patients who completed at least one assessment and exited the program were sent a patient engagement survey to evaluate the patient's experience with digital monitoring for COVID-19. RESULTS The survey was distributed to 491 patients, and 257 responded (52% completion rate). The net promoter score was 85%. Most patients agreed that the RPMP was worthwhile, enabled better management of their COVID-19 symptoms, made them feel more connected to their healthcare team, and helped prevent emergency room visits. Identified themes regarding patient-perceived value of a RPMP included (1) security: a clinical safety net; (2) connection: a link to their clinical team during a period of isolation; and (3) empowerment: an education on the virus and symptom management. CONCLUSION RPMPs are perceived to be of value to oncology patients with COVID-19. Policymakers should consider how these programs can be reimbursed to keep vulnerable patients at home and out of the acute care setting.
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Affiliation(s)
- Bobby Daly
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Tara S Lauria
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Jibran Majeed
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Kimberly Chow
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Olga Strachna
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Ashley Housen
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Ray Baser
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Mark E Robson
- Memorial Sloan Kettering Cancer Center, New York, NY
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15
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Chakravarthy VB, Grabowski MM, Benzel EC, Benzil DL. Neuro-Oncology Practice resources for optimizing care and practice in spinal oncology. Neurooncol Pract 2020; 7:i62-i69. [PMID: 33299575 DOI: 10.1093/nop/npaa050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
As the diagnosis and treatment of systemic cancers continues to improve, increased patient survival has resulted in a rise in the number of patients who develop spinal metastases (SM). Within many areas of oncology, utilization of multidisciplinary care models in the management and decision making of SM patients has proven effective for optimizing care and improving patient safety. Three main goals of an effective clinical pathway include improving outcomes and quality, improving the patient experience, and lowering cost. This paper outlines the strategies employed to optimally establish such a collaborative program for the management of patients with SM, as well as direct providers in and out of the field, patients and caregivers, and practice managers to the appropriate resources.
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Affiliation(s)
- Vikram B Chakravarthy
- Department of Neurosurgery, Cleveland Clinic of Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Matthew M Grabowski
- Department of Neurosurgery, Cleveland Clinic of Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Edward C Benzel
- Department of Neurosurgery, Cleveland Clinic of Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Deborah L Benzil
- Department of Neurosurgery, Cleveland Clinic of Case Western Reserve School of Medicine, Cleveland, Ohio
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16
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From metrics to practice: identifying preventable emergency department visits for patients with cancer. Support Care Cancer 2020; 29:3571-3575. [PMID: 33159604 DOI: 10.1007/s00520-020-05874-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 11/02/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Oncology patients disproportionately utilize the emergency department (ED) for symptom management. At our institution, approximately 1 in 4 visits to the ED by oncology patients led to discharge. We hypothesized that many of the visits leading to ED discharge would be potentially preventable (PP). METHODS We retrospectively characterized ED discharges of oncology patients. Visits were classified by presenting symptom, type of cancer, and time of ED visit. Chart reviewers were additionally asked whether each case could have been safely managed as an outpatient. RESULTS We analyzed 100 ED discharges in a 4-month period in 2016 and 2017. Gastrointestinal (GI) complaints, pain, and fever were the most common presenting symptoms for these visits. We rated 44 of 100 ED discharges as potentially preventable. Given we analyzed only ED discharges which comprise about 25% of ED visits for patients with cancer, overall about 10% of all ED visits by these patients may be preventable. We also found that ED visits without a clinic appointment or phone call to the clinic on the day of ED presentation were more likely to be preventable (51% vs 27%, OR 2.9, p = 0.026). CONCLUSIONS Many ED visits by oncology patients may be preventable and occur for symptoms which can be managed as an outpatient. More of these visits also appear to occur in those who do not reach a clinic member prior to the visit. These findings suggest that improved access to clinics and standardized outpatient symptom management are next steps to consider in preventing ED visits in this vulnerable population.
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17
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Daly B, Gorenshteyn D, Nicholas KJ, Zervoudakis A, Sokolowski S, Perry CE, Gazit L, Baldwin Medsker A, Salvaggio R, Adams L, Xiao H, Chiu YO, Katzen LL, Rozenshteyn M, Reidy-Lagunes DL, Simon BA, Perchick W, Wagner I. Building a Clinically Relevant Risk Model: Predicting Risk of a Potentially Preventable Acute Care Visit for Patients Starting Antineoplastic Treatment. JCO Clin Cancer Inform 2020; 4:275-289. [PMID: 32213093 DOI: 10.1200/cci.19.00104] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To create a risk prediction model that identifies patients at high risk for a potentially preventable acute care visit (PPACV). PATIENTS AND METHODS We developed a risk model that used electronic medical record data from initial visit to first antineoplastic administration for new patients at Memorial Sloan Kettering Cancer Center from January 2014 to September 2018. The final time-weighted least absolute shrinkage and selection operator model was chosen on the basis of clinical and statistical significance. The model was refined to predict risk on the basis of 270 clinically relevant data features spanning sociodemographics, malignancy and treatment characteristics, laboratory results, medical and social history, medications, and prior acute care encounters. The binary dependent variable was occurrence of a PPACV within the first 6 months of treatment. There were 8,067 observations for new-start antineoplastic therapy in our training set, 1,211 in the validation set, and 1,294 in the testing set. RESULTS A total of 3,727 patients experienced a PPACV within 6 months of treatment start. Specific features that determined risk were surfaced in a web application, riskExplorer, to enable clinician review of patient-specific risk. The positive predictive value of a PPACV among patients in the top quartile of model risk was 42%. This quartile accounted for 35% of patients with PPACVs and 51% of potentially preventable inpatient bed days. The model C-statistic was 0.65. CONCLUSION Our clinically relevant model identified the patients responsible for 35% of PPACVs and more than half of the inpatient beds used by the cohort. Additional research is needed to determine whether targeting these high-risk patients with symptom management interventions could improve care delivery by reducing PPACVs.
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Affiliation(s)
- Bobby Daly
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.,Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Dmitriy Gorenshteyn
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kevin J Nicholas
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alice Zervoudakis
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Stefania Sokolowski
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Claire E Perry
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lior Gazit
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Rori Salvaggio
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lynn Adams
- Department of Advanced Practice Providers, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Han Xiao
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yeneat O Chiu
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lauren L Katzen
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Margarita Rozenshteyn
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Brett A Simon
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Wendy Perchick
- Office of the Executive Vice President, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Isaac Wagner
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY
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18
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Daly B, Kuperman G, Zervoudakis A, Baldwin Medsker A, Roy A, Ro AS, Arenas J, Yanamandala HV, Kottamasu R, Salvaggio R, Holland J, Hirsch S, Walters CB, Lauria T, Chow K, Begue A, Rozenshteyn M, Zablocki M, Dhami AK, Silva N, Brown E, Katzen LL, Chiu YO, Perry C, Sokolowski S, Wagner I, Veach SR, Grisham RN, Dang CT, Reidy-Lagunes DL, Simon BA, Perchick W. InSight Care Pilot Program: Redefining Seeing a Patient. JCO Oncol Pract 2020; 16:e1050-e1059. [PMID: 32468925 DOI: 10.1200/op.20.00214] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE Early detection and management of symptoms in patients with cancer improves outcomes. However, the optimal approach to symptom monitoring and management is unknown. InSight Care is a mobile health intervention that captures symptom data and facilitates patient-provider communication to mitigate symptom escalation. PATIENTS AND METHODS Patients initiating antineoplastic treatment at a Memorial Sloan Kettering regional location were eligible. Technology supporting the program included the following: a predictive model that identified patient risk for a potentially preventable acute care visit; a secure patient portal enabling communication, televisits, and daily delivery of patient symptom assessments; alerts for concerning symptoms; and a symptom-trending application. The main outcomes of the pilot were feasibility and acceptability evaluated through enrollment and response rates and symptom alerts, and perceived value evaluated on the basis of qualitative patient and provider interviews. RESULTS The pilot program enrolled 100 high-risk patients with solid tumors and lymphoma (29% of new treatment starts v goal of 25%). Over 6 months of follow-up, the daily symptom assessment response rate was 56% (the goal was 50%), and 93% of patients generated a severe symptom alert. Patients and providers perceived value in the program, and archetypes were developed for program improvement. Enrolled patients were less likely to use acute care than were other high-risk patients. CONCLUSION InSight Care was feasible and holds the potential to improve patient care and decrease facility-based care. Future work should focus on optimizing the cadence of patient assessments, the workforce supporting remote symptom management, and the return of symptom data to patients and clinical teams.
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Affiliation(s)
- Bobby Daly
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Ankita Roy
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alice S Ro
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Raj Kottamasu
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | - Tara Lauria
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kim Chow
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Aaron Begue
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | - Emily Brown
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Yeneat O Chiu
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Claire Perry
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Isaac Wagner
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Chau T Dang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Brett A Simon
- Memorial Sloan Kettering Cancer Center, New York, NY
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Daly B, Michaelis LC, Sprandio JD, Kapke JT, Narra RK, Malosh E, Zervoudakis A, Holland J, Zablocki M. From Theory to Practice: Implementation of Strategies to Reduce Acute Care Visits in Patients With Cancer. Am Soc Clin Oncol Educ Book 2020; 40:85-94. [PMID: 32421450 DOI: 10.1200/edbk_281139] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Patients with cancer frequently seek acute care as a result of complications of their disease and adverse effects of treatment. This acute care comes at high cost to the health care system and often results in suboptimal outcomes for patients and their caregivers. The Department of Health and Human Services has identified this as a gap in our care of patients with cancer and has called for quality-improvement efforts to reduce this acute care. We highlight the efforts of three centers-a community practice, an academic practice, and a cancer center-to reduce acute care for their patients. We describe the foundational principles, the practice innovation and implementation strategy, the initial results, and the lessons learned from these interventions. Each of the described interventions sought to integrate evidence-based best practices for reducing unplanned acute care. The first, a telephone triage system, led to 82% of calls being managed at home and only 2% being directed to an emergency department (ED) or hospital. The second, a 24-hour continuity clinic, led to a 26% reduction in ED utilization for patients with cancer. The third, a digital symptom monitoring and management program for high-risk patients on active treatment, led to a 17% reduction in ED presentations. There is a need for innovative care delivery models to improve the management of symptoms for patients with cancer. Future research is needed to determine the elements of these models with the greatest impact and how successful models can be scaled to other institutions.
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Affiliation(s)
- Bobby Daly
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Laura C Michaelis
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - John D Sprandio
- Consultants in Medical Oncology and Hematology, Broomall, PA
- University of Wisconsin Cancer Center at ProHealth Care, Waukesha, WI
| | - Jonathan T Kapke
- University of Wisconsin Cancer Center at ProHealth Care, Waukesha, WI
| | - Ravi Kishore Narra
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Elizabeth Malosh
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Alice Zervoudakis
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jessie Holland
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Melissa Zablocki
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY
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Hoffner B, Rubin KM. Meeting the Challenge of Immune-Related Adverse Events With Optimized Telephone Triage and Dedicated Oncology Acute Care. J Adv Pract Oncol 2019; 10:9-20. [PMID: 33014514 PMCID: PMC7522662 DOI: 10.6004/jadpro.2019.10.2.10] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have improved outcomes for many patients with advanced cancers. However, managing the immune-related adverse events (irAEs) associated with these agents is challenging. Late recognition and/or inadequate irAE management can result in ICI discontinuation or termination, negatively impacting patient outcomes and increasing unplanned emergency department visits, hospital admissions, and costs of care. Improved clinician training and infrastructure development are needed to adequately address irAEs and maximize the potential benefits of ICIs. Advanced practice providers (APPs) are well positioned to drive these improvements. Two aspects of care may reduce the burden of irAE management: improved telephone triage and the implementation of dedicated oncology acute care services. Evidence-based protocols should be used for telephone triage. Protocol development may benefit from an evaluation of current irAE management guidelines together with resources from the Melanoma Nursing Initiative and Immuno-Oncology Essentials. Patients and their caregivers must be educated to recognize and report early symptoms suggestive of an irAE, thereby supporting triage efforts. Advanced practice providers should also advocate for the development of dedicated oncology acute care facilities staffed with clinicians well trained to recognize, grade, and manage irAEs. This manuscript reviews multiple existing models of telephone triage and dedicated oncology acute care. Oncology APPs are poised to lead the staffing, infrastructure, and educational changes necessary to reduce the burden of irAEs in patients receiving ICI therapy.
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Affiliation(s)
- Brianna Hoffner
- University of Colorado Cancer Center-Anschutz, Aurora, Colorado; and Massachusetts General Hospital, Boston, Massachusetts
| | - Krista M Rubin
- University of Colorado Cancer Center-Anschutz, Aurora, Colorado; and Massachusetts General Hospital, Boston, Massachusetts
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Mrad C, Abougergi MS, Daly B. One Step Forward, Two Steps Back: Trends in Aggressive Inpatient Care at the End of Life for Patients With Stage IV Lung Cancer. J Oncol Pract 2018; 14:e746-e757. [PMID: 30265173 DOI: 10.1200/jop.18.00515] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Patients with metastatic lung cancer are treated with palliative intent. Aggressive care at the end of life is a marker of poor-quality care. National trends and factors related to aggressive inpatient care at the end of life for these patients have not been evaluated. METHODS Patients with stage IV lung cancer and a terminal hospitalization were identified in the National Inpatient Sample database between 1998 and 2014. Longitudinal analysis was conducted to determine trends in aggressive inpatient care at the end of life and multivariate logistic regression was performed to determine associations with patient and hospital characteristics. RESULTS A total of 412,946 patients met the inclusion criteria. From 1998 to 2014, the proportion of patients admitted to the intensive care unit (ICU) during the terminal hospitalization increased from 13.3% to 27.9% (P < .001). The ICU stay translated into a higher mean total cost of care (+$18,461; 95% CI, $17,460 to $19,463). Promisingly, palliative care encounters for terminal hospitalizations also increased during this period from 8.7% to 53.0% (P < .01) and were correlated with a decrease in aggressive care at the end of life. However, this did not offset the trend in increased ICU use; mean total costs for a terminal hospitalization increased from $14,000 to $19,500, adjusted for inflation. A multivariable model demonstrates variation by patient and hospital characteristics in aggressive care use. CONCLUSIONS Among patients with metastatic lung cancer there has been a substantial increase in ICU use during terminal hospitalizations, resulting in high cost for the health care system.
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Affiliation(s)
- Chebli Mrad
- Roswell Park Comprehensive Cancer Center, Buffalo; Memorial Sloan Kettering Cancer Center, New York, NY; University of South Carolina, Greenville, SC
| | - Marwan S Abougergi
- Roswell Park Comprehensive Cancer Center, Buffalo; Memorial Sloan Kettering Cancer Center, New York, NY; University of South Carolina, Greenville, SC
| | - Bobby Daly
- Roswell Park Comprehensive Cancer Center, Buffalo; Memorial Sloan Kettering Cancer Center, New York, NY; University of South Carolina, Greenville, SC
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