1
|
Song MK, Higgins MK, Ward SE, Lee H, Noorani N, Happ MB. Measures of Patient and Surrogate Preparedness for End-of-Life Decision-Making. J Pain Symptom Manage 2024; 67:429-440.e2. [PMID: 38355069 PMCID: PMC11032227 DOI: 10.1016/j.jpainsymman.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/30/2024] [Accepted: 02/02/2024] [Indexed: 02/16/2024]
Abstract
CONTEXT Reliable and valid measures are critical in accurately assessing outcomes of advance care planning interventions (ACP) for end-of-life (EOL) decision-making. OBJECTIVES To develop measures of preparedness for EOL decision-making for patients with end-stage renal disease and their surrogates (an exemplar population). METHODS In this 3-phase study, Phases 1 and 2 included a cross-discipline concept analysis of the preparedness construct, item generation for patient and surrogate scales (82 items), evaluation of content validity and readability, cognitive interviewing, and item reduction. In phase 3, the retained 26 patient and 25 surrogate items were administered to 426 patients and 426 surrogates during a multisite trial of an ACP intervention versus care-as-usual and evaluated internal consistency, 2-week test-retest reliability, and construct validity. RESULTS Scales were reduced to 20 patient and 19 surrogate items during phase 3. Cronbach's alphas were 0.86 (patient) and 0.90 (surrogate). There was a strong correlation between preparedness at baseline and two weeks for both scales (r = 0.66-0.69, P < 0.001). Confirmatory factor analysis and item-response analyses suggested unidimensionality. A significant correlation was shown between patient preparedness and patient decisional conflict (r = -0.53, P < 0.001), and surrogate preparedness and surrogate decision-making confidence (r = 0.44, P < 0.001). Among those who received the ACP intervention, the effect size of change was medium: Cohen's d = 0.54, P < 0.001 for patients and d = 0.57, P < 0.001 for surrogates. CONCLUSIONS The preparedness scales demonstrated strong psychometric properties. Future studies should examine scale performance in other populations.
Collapse
Affiliation(s)
- Mi-Kyung Song
- Nell Hodgson Woodruff School of Nursing (M.K.S., M.K.H., H.L., N.N.), Emory University, 1520 Clifton Road NE, Atlanta, GA 30322, USA.
| | - Melinda K Higgins
- Nell Hodgson Woodruff School of Nursing (M.K.S., M.K.H., H.L., N.N.), Emory University, 1520 Clifton Road NE, Atlanta, GA 30322, USA
| | - Sandra E Ward
- School of Nursing (S.E.W.), University of Wisconsin-Madison, Signe Skott Cooper Hall, 701 Highland Avenue, Madison, WI 53705, USA
| | - Haerim Lee
- Nell Hodgson Woodruff School of Nursing (M.K.S., M.K.H., H.L., N.N.), Emory University, 1520 Clifton Road NE, Atlanta, GA 30322, USA
| | - Naziya Noorani
- Nell Hodgson Woodruff School of Nursing (M.K.S., M.K.H., H.L., N.N.), Emory University, 1520 Clifton Road NE, Atlanta, GA 30322, USA
| | - Mary Beth Happ
- College of Nursing (M.B.H.), The Ohio State University, 1577 Neil Ave, Columbus, OH 43210, USA
| |
Collapse
|
2
|
Song MK, Paul S, Pelkmans J, Ward SE. Pandemic Effects on Stability of End-of-Life Preferences and Patient-Surrogate Dyad Congruence. J Pain Symptom Manage 2024:S0885-3924(24)00671-7. [PMID: 38514021 DOI: 10.1016/j.jpainsymman.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/09/2024] [Accepted: 03/11/2024] [Indexed: 03/23/2024]
Abstract
CONTEXT Whether a largescale disaster alters people's previous decisions about their end-of-life care is unknown. OBJECTIVES We examined the effects of a disaster, the COVID-19 pandemic, on stability of end-of-life care preferences among dialysis patients and on patient-surrogate goals-of-care congruence. METHODS We used a natural experimental design to examine goals-of-care preferences pre- and postexposure to the pandemic during a pragmatic trial testing SPIRIT (sharing patient's illness representations to increase trust), an evidence-based advance care planning (ACP) intervention. There were 151 patient-surrogate dyads who prior to the pandemic lockdown had completed baseline (T1) and postintervention assessments (T2) regarding their goals-of-care preferences in two end-of-life scenarios. Of those 151 dyads, 59 intervention, and 51 usual care dyads consented to be in the present study and completed the goals-of-care tool two additional times, at enrollment (T3) and six months later (T4), along with the COVID stress scale (CSS). Dyad congruence was ascertained by comparing patient and surrogate responses to the goals-of-care tool. RESULTS There were no changes over time in the proportions of patients who chose comfort-care-only in the goals-of-care tool. The proportion of patients who chose comfort-care-only and dyad congruence were higher in SPIRIT compared to usual care, but there was no interaction between that treatment effect and exposure to the pandemic. CSS was associated with neither patients' preferences nor dyad congruence. CONCLUSIONS The pandemic alone did not appear to influence patients' goals-of-care preferences or dyad congruence. This finding supports the stability of value-based end-of-life preferences in general, even during a disaster.
Collapse
Affiliation(s)
- Mi-Kyung Song
- Center for Nursing Excellence in Palliative Care (M.K.S.), Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA.
| | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing (S.P., J.P.), Emory University, Atlanta, Georgia, USA
| | - Jordan Pelkmans
- Nell Hodgson Woodruff School of Nursing (S.P., J.P.), Emory University, Atlanta, Georgia, USA
| | - Sandra E Ward
- School of Nursing (S.E.W.), University of Wisconsin-Madison, Madison, Wisconsin, USA
| |
Collapse
|
3
|
Song MK, Manatunga A, Plantinga L, Metzger M, Kshirsagar AV, Lea J, Abdel-Rahman EM, Jhamb M, Wu E, Englert J, Ward SE. Effectiveness of an Advance Care Planning Intervention in Adults Receiving Dialysis and Their Families: A Cluster Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2351511. [PMID: 38289604 PMCID: PMC10828909 DOI: 10.1001/jamanetworkopen.2023.51511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/26/2023] [Indexed: 02/01/2024] Open
Abstract
Importance Evidence of effectiveness of advance care planning (ACP) strategies for patients receiving dialysis and their families is needed. Objectives To test the effectiveness of an ACP intervention to prepare patients and their surrogates for end-of-life (EOL) decision-making and to improve surrogate bereavement outcomes. Design, Setting, and Participants This cluster randomized clinical trial, An Effectiveness-Implementation Trial of SPIRIT (Sharing Patients' Illness Representations to Increase Trust) in ESRD, was conducted from December 2017 to March 2023 and included 42 dialysis clinics in 5 US states (Georgia, New Mexico, North Carolina, Pennsylvania, and Virginia) randomized to provide intervention or usual care. Recruitment was from February 15, 2018, to January 31, 2022, and patient-surrogate dyads were followed up for 21 months (until January 17, 2023) or until patient death. Intervention Each clinic selected 1 or 2 health care workers (eg, nurse practitioner, registered nurse, or social worker) to conduct 45- to 60-minute ACP discussions with dyads in the clinic or remotely. After March 13, 2020 (commencement of the COVID-19 emergency declaration), all discussions were conducted remotely. An ACP summary was placed in patients' medical records. Main Outcomes and Measures The primary, 2-week preparedness outcomes were dyad congruence on EOL goals of care, patient decisional conflict, surrogate decision-making confidence, and a composite of dyad congruence and surrogate decision-making confidence. Secondary bereavement outcomes were anxiety, depression, and posttraumatic distress 3 months after patient death. To adjust for COVID-19 pandemic effects on bereavement outcomes, a variable to indicate the timing of baseline and 3-month assessment relative to the COVID-19 emergency declaration was created. Results Of the 426 dyads enrolled, 231 were in the intervention clinics, and 195 were in the control clinics. Among all dyads, the mean (SD) patient age was 61.9 (12.7) years, and the mean (SD) surrogate age was 53.7 (15.4) years. At 2 weeks, after adjusting for baseline values, dyad congruence (odds ratio [OR], 1.61; 95% CI, 1.12-2.31; P = .001), decisional conflict scores (β, -0.10; 95% CI, -0.13 to -0.07; P < .001), and the composite (OR, 1.57; 95% CI, 1.06-2.34; P = .03) were higher in the intervention group than in the control group. Surrogate decision-making confidence was similar between groups (β, 0.06; 95% CI, -0.01 to 0.13; P = .12). Among 77 bereaved surrogates, after adjusting for baseline values and assessment timing, intervention group anxiety was lower than control group anxiety (β, -1.55; 95% CI, -3.08 to -0.01; P = .05); however, depression (β, -0.18; 95% CI, -2.09 to 1.73; P = .84) and posttraumatic distress (β, -0.96; 95% CI, -7.39 to 5.46; P = .75) were similar. Conclusions and Relevance In this randomized clinical trial, the ACP intervention implemented by health care workers at dialysis centers improved preparation for EOL decision-making but showed mixed effectiveness on bereavement outcomes. The ACP intervention implemented in dialysis centers may be an effective strategy to the dyad preparation for end-of-life care as opposed to the current focus on advance directives. Trial Registration ClinicalTrials.gov Identifier: NCT03138564.
Collapse
Affiliation(s)
- Mi-Kyung Song
- Center for Nursing Excellence in Palliative Care, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Amita Manatunga
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Laura Plantinga
- Division of Rheumatology, Department of Medicine, University of California, San Francisco
- Division of Nephrology, Department of Medicine, University of California, San Francisco
| | | | - Abhijit V. Kshirsagar
- UNC Kidney Center, University of North Carolina at Chapel Hill School of Medicine
- Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill School of Medicine
| | - Janice Lea
- Division of Renal Medicine, Emory University School of Medicine, Emory University, Atlanta, Georgia
| | - Emaad M. Abdel-Rahman
- Division of Nephrology, University of Virginia School of Medicine, University of Virginia, Charlottesville
| | - Manisha Jhamb
- Division of Renal-Electrolyte, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Emily Wu
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jacob Englert
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | |
Collapse
|
4
|
Donovan HS, Sereika SM, Wenzel LB, Edwards RP, Knapp JE, Hughes SH, Roberge MC, Thomas TH, Klein SJ, Spring MB, Nolte S, Landrum LM, Casey AC, Mutch DG, DeBernardo RL, Muller CY, Sullivan SA, Ward SE. Effects of the WRITE Symptoms Interventions on Symptoms and Quality of Life Among Patients With Recurrent Ovarian Cancers: An NRG Oncology/GOG Study (GOG-0259). J Clin Oncol 2022; 40:1464-1473. [PMID: 35130043 PMCID: PMC9061156 DOI: 10.1200/jco.21.00656] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 11/21/2021] [Accepted: 01/05/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE GOG-259 was a 3-arm randomized controlled trial of two web-based symptom management interventions for patients with recurrent ovarian cancer. Primary aims were to compare the efficacy of the nurse-guided (Nurse-WRITE) and self-directed (SD-WRITE) interventions to Enhanced Usual Care (EUC) in improving symptoms (burden and controllability) and quality of life (QOL). METHODS Patients with recurrent or persistent ovarian, fallopian, or primary peritoneal cancer with 3+ symptoms were eligible for the study. Participants completed baseline (BL) surveys (symptom burden and controllability and QOL) before random assignment. WRITE interventions lasted 8 weeks to develop symptom management plans for three target symptoms. All women received EUC: monthly online symptom assessment with provider reports; online resources; and every 2-week e-mails. Outcomes were evaluated at 8 and 12 weeks after BL. Repeated-measures modeling with linear contrasts evaluated group by time effects on symptom burden, controllability, and QOL, controlling for key covariates. RESULTS Participants (N = 497) reported mean age of 59.3 ± 9.2 years. At BL, 84% were receiving chemotherapy and reported a mean of 14.2 ± 4.9 concurrent symptoms, most commonly fatigue, constipation, and peripheral neuropathy. Symptom burden and QOL improved significantly over time (P < .001) for all three groups. A group by time interaction (P < .001) for symptom controllability was noted whereby both WRITE intervention groups had similar improvements from BL to 8 and 12 weeks, whereas EUC did not improve over time. CONCLUSION Both WRITE Intervention groups showed significantly greater improvements in symptom controllability from BL to 8 and BL to 12 weeks compared with EUC. There were no significant differences between Nurse-WRITE and SD-WRITE. SD-WRITE has potential as a scalable intervention for a future implementation study.
Collapse
Affiliation(s)
- Heidi S. Donovan
- University of Pittsburgh School of Nursing, Pittsburgh, PA
- Magee Womens Hospital of UPMC Hillman Cancer Center, Pittsburgh, PA
| | | | - Lari B. Wenzel
- Medicine and Public Health, University of California, Irvine, CA
| | | | | | | | | | | | - Sara Jo Klein
- University of Pittsburgh School of Nursing, Pittsburgh, PA
| | - Michael B. Spring
- University of Pittsburgh School of Computing and Information, Pittsburgh, PA
| | - Susan Nolte
- Abington Memorial Hospital, Gynecologic Oncology Institute, Abington, PA
| | - Lisa M. Landrum
- Stephenson Cancer Center Gynecologic Cancers Clinic, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | | | - David G. Mutch
- Washington University School of Medicine, Siteman Cancer Center, St Louis, MO
| | | | - Carolyn Y. Muller
- Gynecologic Oncology, UNM School of Medicine, University of New Mexico Albuquerque, NM
| | | | | |
Collapse
|
5
|
Kwekkeboom K, Serlin RC, Ward SE, LeBlanc TW, Ogunseitan A, Cleary J. Revisiting patient-related barriers to cancer pain management in the context of the US opioid crisis. Pain 2021; 162:1840-1847. [PMID: 33337597 PMCID: PMC8119296 DOI: 10.1097/j.pain.0000000000002173] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/11/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT Patient fear of addiction is a well-documented barrier to the use of analgesic medications for cancer pain control. Over the past 2 decades in the United States, an "opioid crisis" has arisen, accompanied by risk messages delivered through news outlets, public health education, and patient-provider communication. The purpose of this study was to determine if patient-related barriers to cancer pain management-specifically, fears of addiction-and related pain outcomes (pain severity, pain interference with daily life, and adequacy of pain management) have worsened over the last 20 years. A sample of 157 outpatients with active recurrent or active metastatic cancer completed the Barriers Questionnaire-II (BQ-II) and measures of pain and analgesic use. We identified 7 comparison studies published between 2002 and 2020 that reported patient-related barriers using the BQ-II. Significant linear relationships were found between later year of publication and greater fear of addiction (harmful effect subscale score, B = 0.0350, R2 = 0.0347, F1,637 = 23.19, P < 0.0001) and between year of publication and more pain management barriers overall (total BQ-II score, B = 0.039, R2 = 0.065, F1,923 = 73.79, P < 0.0001). Relationships between BQ-II scores (harmful effect and total) and pain outcomes did not change over time. Despite worsening in patient-related barriers, the proportion of patients with adequate vs inadequate analgesic use did not differ over time. Notably, 40% of participants reported inadequate analgesic use, a statistic that has not improved in 20 years. Additional research is necessary to clarify factors contributing to changing beliefs. Findings indicate a continuing need for clinical and possibly system/policy-level interventions to support adequate cancer pain management.
Collapse
Affiliation(s)
- Kristine Kwekkeboom
- University of Wisconsin, Madison, School of Nursing, Madison, WI, United States
| | - Ronald C Serlin
- Emeritus, University of Wisconsin, Madison, Department of Educational Psychology, (Serlin), School of Nursing (Ward), Madison, WI, United States
| | - Sandra E Ward
- Emeritus, University of Wisconsin, Madison, Department of Educational Psychology, (Serlin), School of Nursing (Ward), Madison, WI, United States
| | | | - Adeboye Ogunseitan
- Northwestern University, School of Medicine, Evanston, IL, United States
| | - James Cleary
- Indiana University, School of Medicine, Indianapolis, IN, United States
| |
Collapse
|
6
|
Ward SE, Holmes GR, Morgan JL, Broggio JW, Collins K, Richards PD, Reed MWR, Wyld L. Bridging the Age Gap: a prognostic model that predicts survival and aids in primary treatment decisions for older women with oestrogen receptor-positive early breast cancer. Br J Surg 2020; 107:1625-1632. [PMID: 32602959 DOI: 10.1002/bjs.11748] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/28/2020] [Accepted: 05/03/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND A prognostic model was developed and validated using cancer registry data. This underpins an online decision support tool, informing primary treatment choice for women aged 70 years or older with hormone receptor-positive early breast cancer. METHODS Data from women diagnosed between 2002 and 2010 in the English Northern and Yorkshire and West Midlands regions were used to develop the model. Primary treatment options of surgery with adjuvant endocrine therapy or primary endocrine therapy were compared. Models predicting the hazard of breast cancer-specific mortality and hazard of other-cause mortality were combined to derive survival probabilities. The model was validated externally using data from the Eastern Cancer Registration and Information Centre. RESULTS The model was developed using data from 23 842 women, and validated externally on a data set from 14 526 patients. The overall model calibration was good. At 2 and 5 years, predicted mortality from breast cancer and other causes differed from the observed rate by less than 1 per cent. At 5 years, there were slight overpredictions in breast cancer mortality (2629 predicted versus 2556 observed deaths; P = 0·142) and mortality from all causes (6399 versus 6320 respectively; P = 0·583). The discrepancy varied between subgroups. Model discrimination was 0·75 or above for all mortality measures. CONCLUSION A prognostic model for older women with oestrogen receptor-positive early breast cancer was developed and validated in the present study. This forms a basis for an online decision support tool (https://agegap.shef.ac.uk/).
Collapse
Affiliation(s)
- S E Ward
- Department of Health Economics and Decision Science, School for Health and Related Research, Sheffield
| | - G R Holmes
- Department of Health Economics and Decision Science, School for Health and Related Research, Sheffield
| | - J L Morgan
- Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield
| | - J W Broggio
- National Cancer Registration and Analysis Service, Public Heath England, Birmingham, UK.,Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - K Collins
- Centre for Health and Social Care Research, Sheffield Hallam University, Sheffield
| | - P D Richards
- Department of Health Economics and Decision Science, School for Health and Related Research, Sheffield
| | - M W R Reed
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - L Wyld
- Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield
| |
Collapse
|
7
|
Song MK, Ward SE, Hepburn K, Paul S, Kim H, Shah RC, Morhardt DJ, Medders L, Lah JJ, Clevenger CC. Can Persons with Dementia Meaningfully Participate in Advance Care Planning Discussions? A Mixed-Methods Study of SPIRIT. J Palliat Med 2019; 22:1410-1416. [PMID: 31373868 DOI: 10.1089/jpm.2019.0088] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Despite the importance of persons with dementia (PWDs) engaging in advance care planning (ACP) at a time when they are still competent to appoint a surrogate decision maker and meaningfully participate in ACP discussions, studies of ACP in PWDs are rare. Objective: We conducted an intervention development study to adapt an efficacious ACP intervention, SPIRIT (sharing patient's illness representations to increase trust), for PWDs in early stages (recent Montreal Cognitive Assessment [MoCA] score ≥13) and their surrogates and assess whether SPIRIT could help PWDs engage in ACP. Design: A formative expert panel review of the adapted SPIRIT, followed by a randomized trial with qualitative interviews, was conducted. Patient-surrogate dyads were randomized to SPIRIT in person (in a private room in a memory clinic) or SPIRIT remote (via videoconferencing from home). Setting/Subjects: Twenty-three dyads of PWDs and their surrogates were recruited from an outpatient brain health center. Participants completed preparedness outcome measures (dyad congruence on goals of care, patient decisional conflict, and surrogate decision-making confidence) at baseline and two to three days post-intervention, plus a semistructured interview. Levels of articulation of end-of-life wishes of PWDs during SPIRIT sessions were rated (3 = expressed wishes very coherently, 2 = somewhat coherently, and 1 = unable to express coherently). Results: All 23 were able to articulate their end-of-life wishes very or somewhat coherently during the SPIRIT session; of those, 14 PWDs had moderate dementia. While decision-making capacity was higher in PWDs who articulated their wishes very coherently, MoCA scores did not differ by articulation levels. PWDs and surrogates perceived SPIRIT as beneficial, but the preparedness outcomes did not change pre-post. Conclusions: SPIRIT engaged PWDs and surrogates in meaningful ACP discussions, but requires testing of efficacy and long-term outcomes.
Collapse
Affiliation(s)
- Mi-Kyung Song
- Center for Nursing Excellence in Palliative Care, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Sandra E Ward
- School of Nursing, University of Wisconsin-Madison, Madison, Wisconsin
| | - Kenneth Hepburn
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Hyejin Kim
- Red Cross College of Nursing, Chung-Ang University, Seoul, Korea
| | - Raj C Shah
- Family Medicine and Rush Alzheimer's Disease Center, University of Chicago, Chicago, Illinois
| | - Darby J Morhardt
- Department of Preventive Medicine, Cognitive Neurology and Alzheimer's Disease Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Laura Medders
- Emory Integrated Memory Care Clinic, Emory Healthcare, Atlanta, Georgia
| | - James J Lah
- Department of Neurology, School of Medicine, Emory University, Atlanta, Georgia
| | | |
Collapse
|
8
|
Ward SE, Holmes GR, Ring A, Richards PD, Morgan JL, Broggio JW, Collins K, Reed MWR, Wyld L. Adjuvant Chemotherapy for Breast Cancer in Older Women: An Analysis of Retrospective English Cancer Registration Data. Clin Oncol (R Coll Radiol) 2019; 31:444-452. [PMID: 31122807 DOI: 10.1016/j.clon.2019.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 02/13/2019] [Accepted: 02/20/2019] [Indexed: 10/26/2022]
Abstract
AIMS Adjuvant chemotherapy is recommended as a treatment for women with high recurrence risk early breast cancer. Older women are less likely to receive chemotherapy than younger women. This study investigated the impact of chemotherapy on breast cancer-specific survival in women aged 70 + years using English registry data. MATERIALS AND METHODS Cancer registration data were obtained from two English regions from 2002 to 2012 (n = 29 728). The impact of patient-level characteristics on the probability of receiving adjuvant chemotherapy was explored using logistic regression. Survival modelling was undertaken to show the effect of chemotherapy and age/health status on breast cancer-specific survival. Missing data were handled using multiple imputation. RESULTS In total, 11 735 surgically treated early breast cancer patients were identified. Use of adjuvant chemotherapy has increased over time. Younger age at diagnosis, increased nodal involvement, tumour size and grade, oestrogen receptor-negative or human epidermal growth factor receptor 2-positive disease were all associated with increased probability of receiving chemotherapy. Chemotherapy was associated with a significant reduction in the hazard of breast cancer-specific mortality in women with high risk cancer, after adjusting for patient-level characteristics (hazard ratio 0.74, 95% confidence interval 0.67-0.81). DISCUSSION Chemotherapy is associated with an improved breast cancer-specific survival in older women with early breast cancer at high risk of recurrence . Lower rates of chemotherapy use in older women may, therefore, contribute to inferior cancer outcomes. Decisions on potential benefits for individual patients should be made on the basis of life expectancy, treatment tolerance and patient preference.
Collapse
Affiliation(s)
- S E Ward
- Department of Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - G R Holmes
- Department of Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - A Ring
- Breast Unit, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - P D Richards
- Department of Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - J L Morgan
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
| | - J W Broggio
- National Cancer Registration and Analysis Service, Public Heath England, Birmingham, UK; Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - K Collins
- Centre for Health and Social Care Research, Sheffield Hallam University, Sheffield, UK
| | - M W R Reed
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - L Wyld
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
| |
Collapse
|
9
|
Kim H, Park EM, Henry C, Ward SE, Song MK. Control Conditions That Are Neither Usual Care Nor No Treatment in Randomized Trials of Psychoeducational Palliative Care Interventions: A Systematic Review. Am J Hosp Palliat Care 2019; 36:339-347. [PMID: 30343586 PMCID: PMC6444917 DOI: 10.1177/1049909118805936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND: Determining intervention efficacy depends as much on the control group as on the intervention, but little attention has been given to the control condition in psychoeducational trials in palliative care. OBJECTIVES: To examine (1) research practice regarding control conditions that are neither usual care nor no-treatment controls in randomized trials of psychoeducational palliative care interventions and (2) the rationale and completeness of the descriptions of control conditions in trial reports. METHODS: PubMed, EMBASE, PsycINFO, and Web of Science were searched. After screening 1603 articles, 70 full-text articles were assessed for eligibility. The final sample included 9 trial reports. We used the Delphi list for quality assessment and the modified intervention taxonomy checklist to assess active intervention and control conditions. RESULTS: Four trials used an attention control designed to be equivalent to the structure of the active intervention. In another 4, the control condition included some aspects of attention control such that the mode of contact was similar to that in the active intervention, but either the amount or the intensity of attention was not similar. Only 3 trial reports explicitly stated the rationale for the choice of control condition. Although most reports contained delivery mode, materials, duration, frequency, and sequence, none described the qualifications or training required to deliver the control condition. Only 1 report mentioned the fidelity monitoring method, and none included fidelity data. CONCLUSION: Our review of psychoeducational trials in palliative care calls for researchers' attention to appropriate selection, design, conduct and report of control conditions.
Collapse
Affiliation(s)
- Hyejin Kim
- Center for Nursing Excellence in Palliative Care, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Eliza M. Park
- Departments of Psychiatry and Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carrie Henry
- Center for Nursing Excellence in Palliative Care, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Sandra E. Ward
- School of Nursing, University of Wisconsin-Madison, Madison, WI, USA
| | - Mi-Kyung Song
- Center for Nursing Excellence in Palliative Care, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| |
Collapse
|
10
|
Song MK, Paul S, Ward SE, Gilet CA, Hladik GA. One-Year Linear Trajectories of Symptoms, Physical Functioning, Cognitive Functioning, Emotional Well-being, and Spiritual Well-being Among Patients Receiving Dialysis. Am J Kidney Dis 2018; 72:198-204. [PMID: 29395483 PMCID: PMC6057855 DOI: 10.1053/j.ajkd.2017.11.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 11/11/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND This study evaluated 1-year linear trajectories of patient-reported dimensions of quality of life among patients receiving dialysis. STUDY DESIGN Longitudinal observational study. SETTING & PARTICIPANTS 227 patients recruited from 12 dialysis centers. FACTORS Sociodemographic and clinical characteristics. MEASUREMENTS/OUTCOMES Participants completed an hour-long interview monthly for 12 months. Each interview included patient-reported outcome measures of overall symptoms (Edmonton Symptom Assessment System), physical functioning (Activities of Daily Living/Instrumental Activities of Daily Living), cognitive functioning (Patient's Assessment of Own Functioning Inventory), emotional well-being (Center for Epidemiologic Studies Depression Scale, State Anxiety Inventory, and Positive and Negative Affect Schedule), and spiritual well-being (Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale). For each dimension, linear and generalized linear mixed-effects models were used. Linear trajectories of the 5 dimensions were jointly modeled as a multivariate outcome over time. RESULTS Although dimension scores fluctuated greatly from month to month, overall symptoms, cognitive functioning, emotional well-being, and spiritual well-being improved over time. Older compared with younger participants reported higher scores across all dimensions (all P<0.05). Higher comorbidity scores were associated with worse scores in most dimensions (all P<0.01). Nonwhite participants reported better spiritual well-being compared with their white counterparts (P<0.01). Clustering analysis of dimension scores revealed 2 distinctive clusters. Cluster 1 was characterized by better scores than those of cluster 2 in nearly all dimensions at baseline and by gradual improvement over time. LIMITATIONS Study was conducted in a single region of the United States and included mostly patients with high levels of function across the dimensions of quality of life studied. CONCLUSIONS Multidimensional patient-reported quality of life varies widely from month to month regardless of whether overall trajectories improve or worsen over time. Additional research is needed to identify the best approaches to incorporate patient-reported outcome measures into dialysis care.
Collapse
Affiliation(s)
- Mi-Kyung Song
- Center for Nursing Excellence in Palliative Care, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA.
| | - Sudeshna Paul
- Center for Nursing Excellence in Palliative Care, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | - Sandra E Ward
- University of Wisconsin-Madison, School of Nursing, Madison, WI
| | - Constance A Gilet
- UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Gerald A Hladik
- UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| |
Collapse
|
11
|
Song MK, Ward SE, Hepburn K, Paul S, Shah RC, Morhardt DJ. SPIRIT advance care planning intervention in early stage dementias: An NIH stage I behavioral intervention development trial. Contemp Clin Trials 2018; 71:55-62. [PMID: 29870867 DOI: 10.1016/j.cct.2018.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/31/2018] [Accepted: 06/01/2018] [Indexed: 11/25/2022]
Abstract
People in the early stages of Alzheimer's disease and related dementias (ADRD) are encouraged to engage in advance care planning (ACP) while they are still competent to appoint a surrogate decision maker and meaningfully participate in ACP discussions with the surrogate. In this NIH Stage I behavioral intervention development trial, we will adapt and test an efficacious ACP intervention, SPIRIT (Sharing Patient's Illness Representation to Increase Trust), with people with mild dementia and their surrogates to promote open, honest discussions while such discussions about end-of-life care are possible. We will first adapt SPIRIT (in person) to target people with mild dementia and their surrogates through a process of modification-pretesting-refinement using stakeholders (persons with mild dementia, family caregivers, and clinicians) and experts, including adapting the delivery mode to interactive web-based videoconference format (SPIRIT-remote). Then in a 3-group RCT with 120 patient-surrogate dyads, we will evaluate the feasibility and acceptability of SPIRIT in-person and SPIRIT remote, and preliminary efficacy of SPIRIT compared to usual care on preparedness outcomes for end-of-life decision making (dyad congruence on goals of care, patient decisional conflict, and surrogate decision-making confidence) shortly after the intervention. This Stage I research of SPIRIT will generate valuable insights regarding how to improve ACP for people with mild dementia who will progress to an advanced stage of the disease in the foreseeable future. TRIAL REGISTRATION ClinicalTrials.gov NCT03311711, Registered 10/12/2017.
Collapse
Affiliation(s)
- Mi-Kyung Song
- Center for Nursing Excellence in Palliative Care, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States.
| | - Sandra E Ward
- School of Nursing, University of Wisconsin-Madison, Madison, WI, United States
| | - Kenneth Hepburn
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States
| | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States
| | - Raj C Shah
- Family Medicine and Rush Alzheimer's Disease Center, Rush University, Chicago, IL, United States
| | - Darby J Morhardt
- Cognitive Neurology and Alzheimer's Disease Center and Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| |
Collapse
|
12
|
Kwekkeboom KL, Tostrud L, Costanzo E, Coe CL, Serlin RC, Ward SE, Zhang Y. The Role of Inflammation in the Pain, Fatigue, and Sleep Disturbance Symptom Cluster in Advanced Cancer. J Pain Symptom Manage 2018; 55:1286-1295. [PMID: 29360570 PMCID: PMC5899940 DOI: 10.1016/j.jpainsymman.2018.01.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/04/2018] [Accepted: 01/11/2018] [Indexed: 01/08/2023]
Abstract
CONTEXT Symptom researchers have proposed a model of inflammatory cytokine activity and dysregulation in cancer to explain co-occurring symptoms including pain, fatigue, and sleep disturbance. OBJECTIVES We tested the hypothesis that psychological stress accentuates inflammation and that stress and inflammation contribute to one's experience of the pain, fatigue, and sleep disturbance symptom cluster (symptom cluster severity, symptom cluster distress) and its impact (symptom cluster interference with daily life, quality of life). METHODS We used baseline data from a symptom cluster management trial. Adult participants (N = 158) receiving chemotherapy for advanced cancer reported pain, fatigue, and sleep disturbance on enrollment. Before intervention, participants completed measures of demographics, perceived stress, symptom cluster severity, symptom cluster distress, symptom cluster interference with daily life, and quality of life and provided a blood sample for four inflammatory biomarkers (interleukin-1β, interleukin-6, tumor necrosis factor-α, and C-reactive protein). RESULTS Stress was not directly related to any inflammatory biomarker. Stress and tumor necrosis factor-α were positively related to symptom cluster distress, although not symptom cluster severity. Tumor necrosis factor-α was indirectly related to symptom cluster interference with daily life, through its effect on symptom cluster distress. Stress was positively associated with symptom cluster interference with daily life and inversely with quality of life. Stress also had indirect effects on symptom cluster interference with daily life, through its effect on symptom cluster distress. CONCLUSION The proposed inflammatory model of symptoms was partially supported. Investigators should test interventions that target stress as a contributing factor in co-occurring pain, fatigue, and sleep disturbance and explore other factors that may influence inflammatory biomarker levels within the context of an advanced cancer diagnosis and treatment.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Yingzi Zhang
- University of Wisconsin, Madison, Wisconsin, USA
| |
Collapse
|
13
|
Song MK, Unruh ML, Manatunga A, Plantinga LC, Lea J, Jhamb M, Kshirsagar AV, Ward SE. SPIRIT trial: A phase III pragmatic trial of an advance care planning intervention in ESRD. Contemp Clin Trials 2018; 64:188-194. [PMID: 28993286 PMCID: PMC5742022 DOI: 10.1016/j.cct.2017.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 10/03/2017] [Accepted: 10/05/2017] [Indexed: 10/18/2022]
Abstract
Advance care planning (ACP) is a central tenet of dialysis care, but the vast majority of dialysis patients report never engaging in ACP discussions with their care providers. Over the last decade, we have developed and iteratively tested SPIRIT (Sharing Patient's Illness Representation to Increase Trust), a theory-based, patient- and family-centered advance care planning intervention. SPIRIT is a six-step, two-session, face-to-face intervention to promote cognitive and emotional preparation for end-of-life decision making for patients with ESRD and their surrogates. In these explanatory trials, SPIRIT was delivered by trained research nurses. Findings consistently revealed that patients and surrogates in SPIRIT showed significant improvement in preparedness for end-of-life decision making, and surrogates in SPIRIT reported significantly improved post-bereavement psychological outcomes after the patient's death compared to a no treatment comparison condition. As a critical next step, we are conducting an effectiveness-implementation study. This study is a multicenter, clinic-level cluster randomized pragmatic trial to evaluate the effectiveness of SPIRIT delivered by dialysis care providers as part of routine care in free-standing outpatient dialysis clinics, compared to usual care plus delayed SPIRIT implementation. Simultaneously, we will evaluate the implementation of SPIRIT, including sustainability. We will recruit 400 dyads of patients at high risk of death in the next year and their surrogates from 30 dialysis clinics in four states. This trial of SPIRIT will generate novel, meaningful insights about improving ACP in dialysis care. TRIAL REGISTRATION ClinicalTrials.govNCT03138564, registered 05/01/2017.
Collapse
Affiliation(s)
- Mi-Kyung Song
- Center for Nursing Excellence in Palliative Care, Nell Hodgson Woodruff School of Nursing, Emory University, United States.
| | - Mark L Unruh
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM, United States
| | - Amita Manatunga
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Laura C Plantinga
- Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, GA, United States
| | - Janice Lea
- Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, GA, United States
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Abhijit V Kshirsagar
- UNC Kidney Center, Division of Nephrology and Hypertension, Chapel Hill, NC, United States
| | - Sandra E Ward
- School of Nursing, University of Wisconsin-Madison, Madison, WI, United States
| |
Collapse
|
14
|
Burns J, Polus S, Brereton L, Chilcott J, Ward SE, Pfadenhauer LM, Rehfuess EA. Looking beyond the forest: Using harvest plots, gap analysis, and expert consultations to assess effectiveness, engage stakeholders, and inform policy. Res Synth Methods 2017; 9:132-140. [PMID: 29106058 DOI: 10.1002/jrsm.1284] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 10/04/2017] [Accepted: 10/23/2017] [Indexed: 11/09/2022]
Abstract
We describe a combination of methods for assessing the effectiveness of complex interventions, especially where substantial heterogeneity with regard to the population, intervention, comparison, outcomes, and study design of interest is expected. We applied these methods in a recent systematic review of the effectiveness of reinforced home-based palliative care (rHBPC) interventions, which included home-based care with an additional and explicit component of lay caregiver support. We first summarized the identified evidence, deemed inappropriate for statistical pooling, graphically by creating harvest plots. Although very useful as a tool for summary and presentation of overall effectiveness, such graphical summary approaches may obscure relevant differences between studies. Thus, we then used a gap analysis and conducted expert consultations to look beyond the aggregate level at how the identified evidence of effectiveness may be explained. The goal of these supplemental methods was to step outside of the conventional systematic review and explore this heterogeneity from a broader perspective, based on the experience of palliative care researchers and practitioners. The gap analysis and expert consultations provided valuable input into possible underlying explanations in the evidence, which could be helpful in the further adaptation and testing of existing rHBPC interventions or the development and evaluation of new ones. We feel that such a combination of methods could prove accessible, understandable, and useful in informing decisions and could thus help increase the relevance of systematic reviews to the decision-making process.
Collapse
Affiliation(s)
- J Burns
- Institute for Medical Informatics, Biometry and Epidemiology, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - S Polus
- Institute for Medical Informatics, Biometry and Epidemiology, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - L Brereton
- The School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.,College of Health and Social Sciences, University of Lincoln, Lincoln, UK
| | - J Chilcott
- The School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - S E Ward
- The School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - L M Pfadenhauer
- Institute for Medical Informatics, Biometry and Epidemiology, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - E A Rehfuess
- Institute for Medical Informatics, Biometry and Epidemiology, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| |
Collapse
|
15
|
Abstract
BACKGROUND Few studies have examined the process and impact of an advance care planning intervention experienced by surrogate decision-makers of dialysis patients. AIM To explore the perspectives of the bereaved surrogates of dialysis patients on the process and impact of an advance care planning intervention and to compare the perceived impacts of the intervention between African Americans and Whites. DESIGN Qualitative interviews and thematic analysis. SETTING/PARTICIPANTS 24 bereaved surrogates of patients from outpatient dialysis centers were interviewed. Both patients and surrogates had been participants in a larger efficacy study and had received an advance care planning intervention, SPIRIT (Sharing Patient's Illness Representations to Increase Trust). RESULTS Two themes related to the process of SPIRIT were as follows: (1) SPIRIT provided a welcome opportunity to think about and discuss topics that had been avoided and (2) SPIRIT helped patients and surrogates to share their feelings. Four themes of the SPIRIT's impact were as follows: (1) SPIRIT was an eye-opening experience, acquiring knowledge and understanding of the patient's illness and end-of-life care, (2) SPIRIT helped strengthen relationships between patients and surrogates, (3) SPIRIT helped surrogates feel prepared during the time leading up to end-of-life decision-making, and (4) SPIRIT helped surrogates have peace of mind during and after actual end-of-life decision-making. Themes related to SPIRIT's impact on feeling prepared for end-of-life decision-making and the actual decision-making experience more frequently occurred in African Americans than in Whites. CONCLUSION Our data may help explain the beneficial effects of SPIRIT on surrogates, but future trials should include data on control surrogates' perspectives.
Collapse
Affiliation(s)
- Mi-Kyung Song
- 1 Center for Nursing Excellence in Palliative Care, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Maureen Metzger
- 2 School of Nursing, University of Virginia, Charlottesville, VA, USA
| | - Sandra E Ward
- 3 School of Nursing, University of Wisconsin-Madison, Madison, WI, USA
| |
Collapse
|
16
|
Song MK, Ward SE, Lin FC, Hamilton JB, Hanson LC, Hladik GA, Fine JP. Racial Differences in Outcomes of an Advance Care Planning Intervention for Dialysis Patients and Their Surrogates. J Palliat Med 2016; 19:134-42. [PMID: 26840848 DOI: 10.1089/jpm.2015.0232] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND African Americans' beliefs about end-of-life care may differ from those of whites, but racial differences in advance care planning (ACP) outcomes are unknown. OBJECTIVE The aim of this study was to compare the efficacy of an ACP intervention on preparation for end-of-life decision making and post-bereavement outcomes for African Americans and whites on dialysis. METHOD A secondary analysis of data from a randomized trial comparing an ACP intervention (Sharing Patient's Illness Representations to Increase Trust [SPIRIT]) with usual care was conducted. There were 420 participants, 210 patient-surrogate dyads (67.4% African Americans), recruited from 20 dialysis centers in North Carolina. The outcomes of preparation for end-of-life decision making included dyad congruence on goals of care, surrogate decision-making confidence, a composite of the two, and patient decisional conflict assessed at 2, 6, and 12 months post-intervention. Surrogate bereavement outcomes included anxiety, depression, and post-traumatic distress symptoms assessed at 2 weeks, and at 3 and 6 months after the patient's death. RESULTS SPIRIT was superior to usual care in improving dyad congruence (odds ration [OR] = 2.31, p = 0.018), surrogate decision-making confidence (β = 0.18, p = 0.021), and the composite (OR = 2.19, p = 0.028) 2 months post-intervention, but only for African Americans. SPIRIT reduced patient decisional conflict at 6 months for whites and at 12 months for African Americans. Finally, SPIRIT was superior to usual care in reducing surrogates' bereavement depressive symptoms for African Americans but not for whites (β = -3.49, p = 0.003). CONCLUSION SPIRIT was effective in improving preparation for end-of-life decision-making and post-bereavement outcomes in African Americans.
Collapse
Affiliation(s)
- Mi-Kyung Song
- 1 Nell Hodgson School of Nursing, Emory University , Atlanta, Georgia
| | - Sandra E Ward
- 2 School of Nursing, University of Wisconsin-Madison , Madison, Wisconsin
| | - Feng-Chang Lin
- 3 School of Public Health, Department of Biostatistics, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | - Jill B Hamilton
- 4 School of Nursing, Johns Hopkins University , Baltimore, Maryland
| | - Laura C Hanson
- 5 School of Medicine, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | | | - Jason P Fine
- 3 School of Public Health, Department of Biostatistics, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| |
Collapse
|
17
|
O'Sullivan JM, Aguila S, McRae E, Ward SE, Rawley O, Fallon PG, Brophy TM, Preston RJS, Brady L, Sheils O, Chion A, O'Donnell JS. N-linked glycan truncation causes enhanced clearance of plasma-derived von Willebrand factor. J Thromb Haemost 2016; 14:2446-2457. [PMID: 27732771 DOI: 10.1111/jth.13537] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Indexed: 12/31/2022]
Abstract
Essentials von Willebrands factor (VWF) glycosylation plays a key role in modulating in vivo clearance. VWF glycoforms were used to examine the role of specific glycan moieties in regulating clearance. Reduction in sialylation resulted in enhanced VWF clearance through asialoglycoprotein receptor. Progressive VWF N-linked glycan trimming resulted in increased macrophage-mediated clearance. Click to hear Dr Denis discuss clearance of von Willebrand factor in a free presentation from the ISTH Academy SUMMARY: Background Enhanced von Willebrand factor (VWF) clearance is important in the etiology of both type 1 and type 2 von Willebrand disease (VWD). In addition, previous studies have demonstrated that VWF glycans play a key role in regulating in vivo clearance. However, the molecular mechanisms underlying VWF clearance remain poorly understood. Objective To define the molecular mechanisms through which VWF N-linked glycan structures influence in vivo clearance. Methods By use of a series of exoglycosidases, different plasma-derived VWF (pd-VWF) glycoforms were generated. In vivo clearance of these glycoforms was then assessed in VWF-/- mice in the presence or absence of inhibitors of asialoglycoprotein receptor (ASGPR), or following clodronate-induced macrophage depletion. Results Reduced amounts of N-linked and O-linked sialylation resulted in enhanced pd-VWF clearance modulated via ASGPR. In addition to this role of terminal sialylation, we further observed that progressive N-linked glycan trimming also resulted in markedly enhanced VWF clearance. Furthermore, these additional N-linked glycan effects on clearance were ASGPR-independent, and instead involved enhanced macrophage clearance that was mediated, at least in part, through LDL receptor-related protein 1. Conclusion The carbohydrate determinants expressed on VWF regulate susceptibility to proteolysis by ADAMTS-13. In addition, our findings now further demonstrate that non-sialic acid carbohydrate determinants expressed on VWF also play an unexpectedly important role in modulating in vivo clearance through both hepatic ASGPR-dependent and macrophage-dependent pathways. In addition, these data further support the hypothesis that variation in VWF glycosylation may be important in the pathophysiology underlying type 1C VWD.
Collapse
Affiliation(s)
- J M O'Sullivan
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Haemostasis Research Group, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St James's Hospital, Trinity College Dublin, Dublin, Ireland
| | - S Aguila
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Haemostasis Research Group, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St James's Hospital, Trinity College Dublin, Dublin, Ireland
| | - E McRae
- Haemostasis Research Group, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St James's Hospital, Trinity College Dublin, Dublin, Ireland
| | - S E Ward
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Haemostasis Research Group, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St James's Hospital, Trinity College Dublin, Dublin, Ireland
| | - O Rawley
- Haemostasis Research Group, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St James's Hospital, Trinity College Dublin, Dublin, Ireland
| | - P G Fallon
- Inflammation and Immunity Research Group, Institute of Molecular Medicine, St James's Hospital, Trinity College Dublin, Dublin, Ireland
| | - T M Brophy
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Haemostasis Research Group, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St James's Hospital, Trinity College Dublin, Dublin, Ireland
| | - R J S Preston
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - L Brady
- Department of Histopathology, Sir Patrick Dun Research Laboratory, Trinity College Dublin, St James's Hospital Dublin, Dublin, Ireland
| | - O Sheils
- Department of Histopathology, Sir Patrick Dun Research Laboratory, Trinity College Dublin, St James's Hospital Dublin, Dublin, Ireland
| | - A Chion
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Haemostasis Research Group, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St James's Hospital, Trinity College Dublin, Dublin, Ireland
| | - J S O'Donnell
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Haemostasis Research Group, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St James's Hospital, Trinity College Dublin, Dublin, Ireland
- National Centre for Hereditary Coagulation Disorders, St James's Hospital, Dublin, Ireland
| |
Collapse
|
18
|
Abstract
This study extends the operational definition of repression (proposed by Weinberger and his colleagues) to negative emotions other than anxiety. It then relates this measure to the responses to cancer of 67 male and female patients. Repressors differed from patients with other coping styles; they reported fewer and less severe side effects of treatment and less information exchange (communication) with significant others. These findings are discussed in relation to other research on differences in the way people tolerate and report physical sensations.
Collapse
|
19
|
Song MK, DeVito Dabbs A, Ward SE. A SMART design to optimize treatment strategies for patient and family caregiver outcomes. Nurs Outlook 2016; 64:299-305. [DOI: 10.1016/j.outlook.2016.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 04/18/2016] [Accepted: 04/30/2016] [Indexed: 11/27/2022]
|
20
|
Abstract
Dysmenorrhea is highly prevalent and is the leading cause of work and school absences among women of reproductive age. However, self-management of dysmenorrhea is not well understood in the US, and little evidence is available on factors that influence dysmenorrhea self-management. Guided by the Common Sense Model, we examined women's representations of dysmenorrhea (beliefs about causes, symptoms, consequences, timeline, controllability, coherence, and emotional responses), described their dysmenorrhea self-management behaviors, and investigated the relationship between representations and self-management behaviors. We conducted a cross-sectional, web-based survey of 762 adult women who had dysmenorrhea symptoms in the last six months. Participants had varied beliefs about the causes of their dysmenorrhea symptoms, which were perceived as a normal part of life. Dysmenorrhea symptoms were reported as moderately severe, with consequences that moderately affected daily life. Women believed they understood their symptoms moderately well and perceived them as moderately controllable but them to continue through menopause. Most women did not seek professional care but rather used a variety of pharmacologic and complementary health approaches. Care-seeking and use of self-management strategies were associated with common sense beliefs about dysmenorrhea cause, consequences, timeline, and controllability. The findings may inform development and testing of self-management interventions that address dysmenorrhea representations and facilitate evidence-based management. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Chen X Chen
- Postdoctoral Fellow, Indiana University School of Nursing, 600 Barnhill Drive, NU 414, Indianapolis, IN 46202
| | | | - Sandra E Ward
- Professor Emerita, School of Nursing, University of Wisconsin-Madison, Madison, WI
| |
Collapse
|
21
|
Song MK, Ward SE, Hanson LC, Metzger M, Kim S. Determining Consistency of Surrogate Decisions and End-of-Life Care Received with Patient Goals-of-Care Preferences. J Palliat Med 2016; 19:610-6. [PMID: 26982909 DOI: 10.1089/jpm.2015.0349] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Care consistent with preferences is the goal of advance care planning (ACP). However, comparing written preferences to actual end-of-life care may not capture consistency of care with preferences. OBJECTIVE We evaluated four additional types of consistency, using prospective data on written preferences and active clinical decision making by patients and their surrogates. METHODS Secondary analysis of data was done from a trial of an ACP intervention for patient-surrogate dyads. Forty-five patients died during the trial and comprised the sample for the analysis. Sources of data included patients' preferences in a written goals-of-care tool, medical record reviews, and two-week postbereavement interviews with surrogates to complement medical record reviews. RESULTS Twenty-four patients (53.3%) received care consistent with written preferences and 11 (24.4%) inconsistent with written preferences. The remaining 10 patients (22.2%) died suddenly with no opportunity for treatment decision making. Eleven (24.4%) were able to participate in decision making with their surrogates; of those, 9 (81.8%) received care consistent with their expressed preferences. Twenty-two patients were incapacitated and thus the surrogate made treatment decisions alone; of those, 18 (81.8%) made decisions consistent with the patient's written preference. CONCLUSIONS Simply comparing documented preferences for end-of-life care and medical records of care delivered does not adequately reflect the process of ACP and treatment decision making at the end of life. To understand consistency between preferences and end-of-life care, investigators need data on written and real-time expressed preferences.
Collapse
Affiliation(s)
- Mi-Kyung Song
- 1 Center for Nursing Excellence in Palliative Care, Nell Hodgson Woodruff School of Nursing, Emory University , Atlanta, Georgia
| | - Sandra E Ward
- 2 School of Nursing, University of Wisconsin-Madison , Madison, Wisconsin
| | - Laura C Hanson
- 3 School of Medicine, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | - Maureen Metzger
- 4 School of Nursing, University of Virginia , Charlottesville, Virginia
| | - SuHyun Kim
- 5 School of Nursing, Kyungpook National University , Daegu, Korea
| |
Collapse
|
22
|
Affiliation(s)
- Mi-Kyung Song
- School of Nursing; University of North Carolina at Chapel Hill; Chapel Hill NC USA
| | - Sandra E. Ward
- School of Nursing; University of Wisconsin-Madison; Madison WI USA
| |
Collapse
|
23
|
Song MK, Ward SE, Fine JP, Hanson LC, Lin FC, Hladik GA, Hamilton JB, Bridgman JC. Advance care planning and end-of-life decision making in dialysis: a randomized controlled trial targeting patients and their surrogates. Am J Kidney Dis 2015; 66:813-22. [PMID: 26141307 DOI: 10.1053/j.ajkd.2015.05.018] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 05/21/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND Few trials have examined long-term outcomes of advance care planning (ACP) interventions. We examined the efficacy of an ACP intervention on preparation for end-of-life decision making for dialysis patients and surrogates and for surrogates' bereavement outcomes. STUDY DESIGN A randomized trial compared an ACP intervention (Sharing Patient's Illness Representations to Increase Trust [SPIRIT]) to usual care alone, with blinded outcome assessments. SETTING & PARTICIPANTS 420 participants (210 dyads of prevalent dialysis patients and their surrogates) from 20 dialysis centers. INTERVENTION Every dyad received usual care. Those randomly assigned to SPIRIT had an in-depth ACP discussion at the center and a follow-up session at home 2 weeks later. OUTCOMES & MEASUREMENTS PRIMARY OUTCOMES preparation for end-of-life decision making, assessed for 12 months, included dyad congruence on goals of care at end of life, patient decisional conflict, surrogate decision-making confidence, and a composite of congruence and surrogate decision-making confidence. SECONDARY OUTCOMES bereavement outcomes, assessed for 6 months, included anxiety, depression, and posttraumatic distress symptoms completed by surrogates after patient death. RESULTS PRIMARY OUTCOMES adjusting for time and baseline values, dyad congruence (OR, 1.89; 95% CI, 1.1-3.3), surrogate decision-making confidence (β=0.13; 95% CI, 0.01-0.24), and the composite (OR, 1.82; 95% CI, 1.0-3.2) were better in SPIRIT than controls, but patient decisional conflict did not differ between groups (β=-0.01; 95% CI, -0.12 to 0.10). SECONDARY OUTCOMES 45 patients died during the study. Surrogates in SPIRIT had less anxiety (β=-1.13; 95% CI, -2.23 to -0.03), depression (β=-2.54; 95% CI, -4.34 to -0.74), and posttraumatic distress (β=-5.75; 95% CI, -10.9 to -0.64) than controls. LIMITATIONS Study was conducted in a single US region. CONCLUSIONS SPIRIT was associated with improvements in dyad preparation for end-of-life decision making and surrogate bereavement outcomes.
Collapse
Affiliation(s)
- Mi-Kyung Song
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Sandra E Ward
- School of Nursing, University of Wisconsin-Madison, Madison, WI
| | - Jason P Fine
- School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Laura C Hanson
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Feng-Chang Lin
- School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | - Jessica C Bridgman
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC
| |
Collapse
|
24
|
Zoëga S, Ward SE, Sigurdsson GH, Aspelund T, Sveinsdottir H, Gunnarsdottir S. Quality Pain Management Practices in a University Hospital. Pain Manag Nurs 2015; 16:198-210. [DOI: 10.1016/j.pmn.2014.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 06/18/2014] [Accepted: 06/18/2014] [Indexed: 12/19/2022]
|
25
|
Song MK, Ward SE, Hladik GA, Bridgman JC, Gilet CA. Depressive symptom severity, contributing factors, and self-management among chronic dialysis patients. Hemodial Int 2015; 20:286-92. [PMID: 25998623 DOI: 10.1111/hdi.12317] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Despite the high prevalence of depressive symptoms in patients receiving chronic dialysis, there has been inadequate attention to patient-related barriers to management of depressive symptoms, such as factors identified by these patients as contributing to their symptoms, and how they responded to the symptoms. Participants (N = 210) in an ongoing longitudinal observational study of multidimensional quality of life in patients receiving chronic dialysis completed a battery of measures monthly for 12 months. For each patient at each measurement point, an event report was generated if he or she scored outside of the normal range on the depressive symptom scale (Center for Epidemiologic Studies Depression Scale-Short Form [CESD-SF] ≥10) or expressed suicidal ideation. Of the 210 participants, 100 (47.6%) had a CESD-SF score ≥10 at least once resulting in 290 event reports. Of these 100 participants, 15 (15%) had also reported suicidal ideation in addition to having depressive symptoms. The most frequently stated contributing factors included "managing comorbid conditions and complications" (56 event reports, 19.3%), "being on dialysis" (50, 17.2%), "family or other personal issues" (37, 12.8%), and "financial difficulties" (31, 10.7%). On 11 event reports (3.8%) participants had been unaware of their depressive symptoms. On 119 event reports (41%) participants reported that they discussed these symptoms with their dialysis care providers or primary care providers, while on 171 event reports (59%) symptoms were not discussed with their health-care providers. The prevalence of depressive symptoms is high and many patients lack knowledge about effective self-management strategies.
Collapse
Affiliation(s)
- Mi-Kyung Song
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sandra E Ward
- University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Gerald A Hladik
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,UNC Kidney Center, Chapel Hill, North Carolina, USA
| | - Jessica C Bridgman
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Constance A Gilet
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,UNC Kidney Center, Chapel Hill, North Carolina, USA
| |
Collapse
|
26
|
Song MK, Ward SE. Assessment effects in educational and psychosocial intervention trials: an important but often-overlooked problem. Res Nurs Health 2015; 38:241-7. [PMID: 25728502 DOI: 10.1002/nur.21651] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2015] [Indexed: 11/10/2022]
Abstract
Baseline assessments and repeated measures are an essential part of educational and psychosocial intervention trials, but merely measuring an outcome of interest can modify that outcome, either by the measurement process alone or by interacting with the intervention to strengthen or weaken the intervention effects. Assessment effects can result in biased estimates of intervention effects and may not be controlled by the usual two-group randomized controlled trial design. In this paper, we review the concept of assessment effects and other related phenomena, briefly describe study designs that estimate assessment effects separately from intervention effects and discuss their strengths and limitations, review evidence regarding the strength of assessment effects in intervention trials targeting behavior change, and discuss implications for intervention research.
Collapse
Affiliation(s)
- Mi-Kyung Song
- Associate Professor and Beerstecher and Blackwell Term Distinguished Scholar, School of Nursing, University of North Carolina at Chapel Hill, 7460 Carrington Hall, Chapel Hill, NC, 27599
| | - Sandra E Ward
- Helen Denne Schulte Professor Emerita, School of Nursing, University of Wisconsin-Madison, Madison, WI
| |
Collapse
|
27
|
Dalley C, Basarir H, Wright JG, Fernando M, Pearson D, Ward SE, Thokula P, Krishnankutty A, Wilson G, Dalton A, Talley P, Barnett D, Hughes D, Porter NR, Reilly JT, Snowden JA. Specialist integrated haematological malignancy diagnostic services: an Activity Based Cost (ABC) analysis of a networked laboratory service model. J Clin Pathol 2015; 68:292-300. [PMID: 25631214 DOI: 10.1136/jclinpath-2014-202624] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS Specialist Integrated Haematological Malignancy Diagnostic Services (SIHMDS) were introduced as a standard of care within the UK National Health Service to reduce diagnostic error and improve clinical outcomes. Two broad models of service delivery have become established: 'co-located' services operating from a single-site and 'networked' services, with geographically separated laboratories linked by common management and information systems. Detailed systematic cost analysis has never been published on any established SIHMDS model. METHODS We used Activity Based Costing (ABC) to construct a cost model for our regional 'networked' SIHMDS covering a two-million population based on activity in 2011. RESULTS Overall estimated annual running costs were £1 056 260 per annum (£733 400 excluding consultant costs), with individual running costs for diagnosis, staging, disease monitoring and end of treatment assessment components of £723 138, £55 302, £184 152 and £94 134 per annum, respectively. The cost distribution by department was 28.5% for haematology, 29.5% for histopathology and 42% for genetics laboratories. Costs of the diagnostic pathways varied considerably; pathways for myelodysplastic syndromes and lymphoma were the most expensive and the pathways for essential thrombocythaemia and polycythaemia vera being the least. CONCLUSIONS ABC analysis enables estimation of running costs of a SIHMDS model comprised of 'networked' laboratories. Similar cost analyses for other SIHMDS models covering varying populations are warranted to optimise quality and cost-effectiveness in delivery of modern haemato-oncology diagnostic services in the UK as well as internationally.
Collapse
Affiliation(s)
- C Dalley
- Departments of Haematology and Histopathology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - H Basarir
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - J G Wright
- Departments of Haematology and Histopathology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - M Fernando
- Departments of Haematology and Histopathology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - D Pearson
- Departments of Haematology and Histopathology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - S E Ward
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - P Thokula
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - A Krishnankutty
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - G Wilson
- Sheffield Diagnostic Genetics Service, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - A Dalton
- Sheffield Diagnostic Genetics Service, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - P Talley
- Sheffield Diagnostic Genetics Service, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - D Barnett
- Departments of Haematology and Histopathology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - D Hughes
- Departments of Haematology and Histopathology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N R Porter
- Departments of Haematology and Histopathology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - J T Reilly
- Departments of Haematology and Histopathology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - J A Snowden
- Departments of Haematology and Histopathology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| |
Collapse
|
28
|
Rafia R, Ward SE. Approaches Used to Model the Relationship Between Progression-Free Survival (PFS) / Time-To-Progression (TTP) And Overall Survival (OS) Within Health Economic Models of Cancer Therapies. Value Health 2014; 17:A557. [PMID: 27201831 DOI: 10.1016/j.jval.2014.08.1834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- R Rafia
- University of Sheffield, Sheffield, UK
| | - S E Ward
- University of Sheffield, Sheffield, UK
| |
Collapse
|
29
|
Song MK, Ward SE. Decisions about dialysis and other life-sustaining treatments should not be made separately. Am J Kidney Dis 2014; 64:817. [PMID: 25343998 DOI: 10.1053/j.ajkd.2014.06.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 06/23/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Mi-Kyung Song
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | |
Collapse
|
30
|
Abstract
BACKGROUND A growing number of elderly patients with end-stage renal disease start dialysis. We examined elderly (≥65 years) patients' views about their decision-making experience after starting dialysis in comparison with patients aged 50-64 years, and patients ≤49 years. METHODS Ninety-nine patients from 15 outpatient dialysis centers in North Carolina, USA completed a semi-structured interview asking them about the context of decision-making and their decision-making experience, and a 10-item investigator-developed Informed Decision-Making (IDM) questionnaire with binary response options (yes/no). RESULTS While IDM scores were low for all three groups (<5 out of 10), they were significantly lower for the older group compared to the other two younger groups (p = 0.02). A significantly lower percentage of the older group said that the doctor explained underlying conditions that led to kidney failure (p = 0.04), the impact of dialysis on daily life (p = 0.04), and the life-long need for dialysis (p < 0.01), and that the doctor tried to make sure the patient understood the information (p = 0.01). Also a significantly higher percentage of elderly patients felt the decision was made by the doctor rather than on their own or with their family, or collaboratively with the doctor (p = 0.04). CONCLUSIONS Informed decision-making is significantly poorer in patients aged 65 years or older than in younger patients. Clinicians should communicate clearly about the benefits and burdens of dialysis to older adults and provide an opportunity for them to understand the significant trade-offs that dialysis may require.
Collapse
Affiliation(s)
- Mi-Kyung Song
- Adult and Geriatric Health Division, School of Nursing, University of North Carolina at Chapel Hill, 7460 Carrington Hall, Chapel Hill, NC, 27599-7460, USA,
| | | |
Collapse
|
31
|
Song MK, Ward SE, Bair E, Weiner LJ, Bridgman JC, Hladik GA, Gilet CA. Patient-reported cognitive functioning and daily functioning in chronic dialysis patients. Hemodial Int 2014; 19:90-9. [PMID: 25110172 DOI: 10.1111/hdi.12202] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Subjective cognitive impairment negatively affects daily functioning, health-related quality of life, and health care consumption, and is predictive of future cognitive decline in many patient populations. However, no subjective measures of multidimensional cognitive functioning have been evaluated for dialysis patients. Our purposes were to examine (1) the association between patient-reported (subjective) cognitive functioning and objective cognitive functioning and (2) the relationships between subjective and objective cognitive functioning and everyday functioning of dialysis patients. We used baseline data from an ongoing longitudinal observational study of trajectories in dialysis patients' multidimensional quality of life. One hundred thirty-five patients completed a telephone-based neuropsychological battery (Brief Test of Adult Cognition by Telephone, a measure of objective cognitive functioning), a measure of subjective cognitive functioning (Patient's Assessment of Own Functioning Inventory), and measures of everyday functioning (Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL] scales). After controlling for age and education, there was a modest correlation (r = 0.33, P > 0.001) between subjective and objective cognitive functioning. Multivariate logistic regression models showed subjective, but not objective, cognitive functioning was a significant predictor of both ADLs and IADLs. The findings suggest the potential clinical value of subjective measures of cognitive functioning, not to replace objective measures or diagnostic tests, but rather to optimize the meaningfulness of clinical assessment and management.
Collapse
Affiliation(s)
- Mi-Kyung Song
- Adult/Geriatric Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | | | | | | | | | | |
Collapse
|
32
|
Donovan HS, Ward SE, Sereika SM, Knapp JE, Sherwood PR, Bender CM, Edwards RP, Fields M, Ingel R. Web-based symptom management for women with recurrent ovarian cancer: a pilot randomized controlled trial of the WRITE Symptoms intervention. J Pain Symptom Manage 2014; 47:218-30. [PMID: 24018206 PMCID: PMC3932314 DOI: 10.1016/j.jpainsymman.2013.04.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Revised: 04/10/2013] [Accepted: 04/19/2013] [Indexed: 11/23/2022]
Abstract
CONTEXT Little research has focused on symptom management among women with ovarian cancer. Written Representational Intervention To Ease Symptoms (WRITE Symptoms) is an educational intervention delivered through asynchronous web-based message boards between a study participant and a nurse. OBJECTIVES We evaluated WRITE Symptoms for 1) feasibility of conducting the study via message boards, 2) system usability, 3) participant satisfaction, and 4) initial efficacy. METHODS Participants were 65 women (mean age, 56.5; SD = 9.23) with recurrent ovarian cancer randomized using minimization with race/ethnicity (non-Hispanic white vs. minority) as the stratification factor. Measures were obtained at baseline and two and six weeks after intervention. Outcomes were feasibility of conducting the study, system usability, participant satisfaction, and efficacy (symptom severity, distress, consequences, and controllability). RESULTS Fifty-six (87.5%) participants were retained, and the mean usability score (range 1-7) was 6.18 (SD = 1.29). All satisfaction items were scored at 5 (of 7) or higher. There were significant between-group effects at T2 for symptom distress, with those in the WRITE Symptoms group reporting lower distress than those in the control group [t(88.4) = -2.57; P = 0.012], with a similar trend for symptom severity [t(40.4) = -1.95; P = 0.058]. Repeated measures analysis also supported a group effect, with those in the WRITE Symptoms group reporting lower symptom distress than those in the control condition [F(1, 56.7) = 4.59; P = 0.037]. CONCLUSION Participants found the intervention and assessment system easy to use and had high levels of satisfaction. Initial efficacy was supported by decreases in symptom severity and distress.
Collapse
Affiliation(s)
- Heidi S Donovan
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA.
| | - Sandra E Ward
- University of Wisconsin-Madison School of Nursing, Madison, Wisconsin, USA
| | - Susan M Sereika
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Judith E Knapp
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Paula R Sherwood
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Catherine M Bender
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | | | - Margaret Fields
- University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Renee Ingel
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA; Carlow University, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
33
|
Zoëga S, Sveinsdottir H, Sigurdsson GH, Aspelund T, Ward SE, Gunnarsdottir S. Quality pain management in the hospital setting from the patient's perspective. Pain Pract 2014; 15:236-46. [PMID: 24433333 DOI: 10.1111/papr.12166] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 11/02/2013] [Indexed: 01/24/2023]
Abstract
BACKGROUND Pain management is a crucial issue for patients, and patients' perception of care is an important quality outcome criterion for health care institutions. Pain remains a common problem in hospitals, with subsequent deleterious effects on well-being. OBJECTIVES To assess the epidemiology of pain (frequency, severity, and interference), patient participation in pain treatment decisions, and patient satisfaction with care in a hospital setting. METHODS A point-prevalence study was conducted. Data were collected with the American Pain Society Patient Outcome Questionnaire (Icelandic version). Participants (n = 308) were ≥ 18 years old, alert, and hospitalized for ≥ 24 hours. RESULTS The response rate was 73%. The mean age of participants was 67.5 (SD = 17.4; range 18 to 100) years, and 49% were men. Pain prevalence in the past 24 hours was 83%, mean worst pain severity was 4.6 (SD = 3.1), and 35% experienced severe pain (≥ 7 on 0 to 10 scale). Moderate to severe interference with activities and sleep was experienced by 36% and 29% of patients respectively. Patient participation in decision making was weakly associated with spending less time in severe pain and better pain relief. Patient satisfaction was related to spending less time in severe pain, better pain relief, and lower pain severity (P < 0.05). CONCLUSIONS Pain was both prevalent and severe in the hospital, but patient participation in decision making was related to better outcomes. Optimal pain management, with emphasis on patient participation in decision making, should be encouraged in an effort to improve the quality of care in hospitals.
Collapse
Affiliation(s)
- Sigridur Zoëga
- Surgical Services, Landspítali - The National University Hospital of Iceland, Reykjavik, Iceland; Faculty of Nursing, University of Iceland, Reykjavik, Iceland
| | | | | | | | | | | |
Collapse
|
34
|
Song MK, Lin FC, Gilet CA, Arnold RM, Bridgman JC, Ward SE. Patient perspectives on informed decision-making surrounding dialysis initiation. Nephrol Dial Transplant 2013; 28:2815-23. [PMID: 23901048 PMCID: PMC3811056 DOI: 10.1093/ndt/gft238] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 04/15/2013] [Accepted: 04/15/2013] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Careful patient-clinician shared decision-making about dialysis initiation has been promoted, but few studies have addressed patient perspectives on the extent of information provided and how decisions to start dialysis are made. METHODS Ninety-nine maintenance dialysis patients recruited from 15 outpatient dialysis centers in North Carolina completed semistructured interviews on information provision and communication about the initiation of dialysis. These data were examined with content analysis. In addition, informed decision-making (IDM) scores were created by summing patient responses (yes/no) to 10 questions about the decision-making. RESULTS The mean IDM score was 4.4 (of 10; SD = 2.0); 67% scored 5 or lower. Age at the time of decision-making (r = -0.27, P = 0.006), years of education (r = 0.24, P = 0.02) and presence of a warning about progressing to end-stage kidney disease (t = 2.9, P = 0.005) were significantly associated with IDM scores. Nearly 70% said that the risks and burdens of dialysis were not mentioned at all, and only one patient recalled that the doctor offered the option of not starting dialysis. While a majority (67%) said that they felt they had no choice about starting dialysis (because the alternative would be death) or about dialysis modality, only 21.2% said that they had felt rushed to make a decision. About one-third of the patients perceived that the decision to start dialysis and modality was already made by the doctor. CONCLUSIONS A majority of patients felt unprepared and ill-informed about the initiation of dialysis. Improving the extent of IDM about dialysis may optimize patient preparation prior to starting treatment and their perceptions about the decision-making process.
Collapse
Affiliation(s)
- Mi-Kyung Song
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Feng-Chang Lin
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Constance A. Gilet
- UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | | |
Collapse
|
35
|
Abstract
BACKGROUND The role played by emergency contacts can be extensive particularly for chronically seriously ill patients. If the patient's condition suddenly deteriorates, the emergency contact may be asked to make decisions that should instead fall to a designated surrogate decision-maker. AIMS To describe a process used to help chronically seriously ill patients identify a surrogate during study enrollment and to describe whether these surrogates were the same as the documented emergency contacts. DESIGN A descriptive cross-sectional study using eligibility assessment and baseline data from an efficacy trial. The parent trial tests the effects of an end-of-life communication intervention on patient and surrogate decision-maker outcomes, and thus, it was important to identify the surrogate. The study recruiter used a short battery of investigator-developed questions to help patients identify a surrogate. SETTING/PARTICIPANTS Patients were 94 self-identified African Americans or Caucasians recruited from 18 outpatient dialysis centers, receiving dialysis for ≥6 months, with Charlson Comorbidity Index of ≥6 or 5 and hospitalized in the last 6 months. RESULTS When first approached, only three patients had a designated and documented surrogate. The remaining 91 selected a surrogate during the surrogate identification process. Of the 94 surrogates who were named, only 60 (63.8%) were also listed in the medical record as the emergency contact. CONCLUSIONS In roughly one-third of instances, the selected surrogate was not the same person listed in official medical records as the emergency contact, which may pose potential problems in medical decision-making in the absence of advance directives.
Collapse
Affiliation(s)
- Mi-Kyung Song
- School of Nursing, University of North Carolina, Chapel Hill, NC, USA.
| | | |
Collapse
|
36
|
Abstract
BACKGROUND Use of composite variables is a common practice, but knowledge about what researchers should consider when creating composite variables is lacking. OBJECTIVE The purpose of this paper was to present methods used to create composite variables with attention to advantages and disadvantages. METHODS Methods of simple averaging, weighted averaging, and meaningful grouping to create composite variables are described briefly, and the context in which one method might be more suitable than the others is discussed. Study examples and comparisons of statistical power among these methods as well as Bonferroni correction are described. DISCUSSION Each approach to creating composite variables has advantages and disadvantages that researchers should weigh carefully. With normally distributed data, composite variables provide the greatest increases in power when the original variables (that make up the composite variable) have similar associations with the outside outcome variable.
Collapse
Affiliation(s)
- Mi-Kyung Song
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
| | | | | | | |
Collapse
|
37
|
Kwekkeboom KL, Abbott-Anderson K, Cherwin C, Roiland R, Serlin RC, Ward SE. Pilot randomized controlled trial of a patient-controlled cognitive-behavioral intervention for the pain, fatigue, and sleep disturbance symptom cluster in cancer. J Pain Symptom Manage 2012; 44:810-22. [PMID: 22771125 PMCID: PMC3484234 DOI: 10.1016/j.jpainsymman.2011.12.281] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Revised: 11/29/2011] [Accepted: 12/01/2011] [Indexed: 11/21/2022]
Abstract
CONTEXT Pain, fatigue, and sleep disturbance commonly co-occur in patients receiving treatment for advanced cancer. OBJECTIVES A pilot randomized controlled trial was conducted to assess initial efficacy of a patient-controlled cognitive-behavioral (CB) intervention for the pain, fatigue, and sleep disturbance symptom cluster. METHODS Eighty-six patients with advanced lung, prostate, colorectal, or gynecologic cancers receiving treatment at a comprehensive cancer center were stratified by recruitment clinics (chemotherapy and radiation therapy) and randomized to intervention or control groups. Forty-three patients were assigned to receive training in and use of up to 12 relaxation, imagery, or distraction exercises delivered via an MP3 player for two weeks during cancer treatment. Forty-three patients were assigned to a waitlist control condition for the same two week period. Outcomes included symptom cluster severity and overall symptom interference with daily life measured at baseline (Time 1) and two weeks later (Time 2). RESULTS Eight participants dropped out; 78 completed the study and were analyzed (36 intervention and 42 control subjects). Participants used the CB strategies an average of 13.65 times (SD=6.98). Controlling for baseline symptom cluster severity and other relevant covariates, it was found that the symptom cluster severity at Time 2 was lower in the intervention group (M(Adj)=2.99, SE=0.29) than in the waitlist group (M(Adj)=3.87, SE=0.36), F(1, 65)=3.57, P=0.032. Symptom interference with daily life did not differ between groups. No significant adverse events were noted with the CB intervention. CONCLUSION Findings suggest that the CB intervention may be an efficacious approach to treating the pain, fatigue, and sleep disturbance symptom cluster. Future research is planned to confirm efficacy and test mediators and moderators of intervention effects.
Collapse
|
38
|
Degen B, Ward SE, Lemes MR, Navarro C, Cavers S, Sebbenn AM. Verifying the geographic origin of mahogany (Swietenia macrophylla King) with DNA-fingerprints. Forensic Sci Int Genet 2012; 7:55-62. [PMID: 22770645 DOI: 10.1016/j.fsigen.2012.06.003] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 05/18/2012] [Accepted: 06/03/2012] [Indexed: 11/26/2022]
Abstract
Illegal logging is one of the main causes of ongoing worldwide deforestation and needs to be eradicated. The trade in illegal timber and wood products creates market disadvantages for products from sustainable forestry. Although various measures have been established to counter illegal logging and the subsequent trade, there is a lack of practical mechanisms for identifying the origin of timber and wood products. In this study, six nuclear microsatellites were used to generate DNA fingerprints for a genetic reference database characterising the populations of origin of a large set of mahogany (Swietenia macrophylla King, Meliaceae) samples. For the database, leaves and/or cambium from 1971 mahogany trees sampled in 31 stands from Mexico to Bolivia were genotyped. A total of 145 different alleles were found, showing strong genetic differentiation (δ(Gregorious)=0.52, F(ST)=0.18, G(ST(Hedrick))=0.65) and clear correlation between genetic and spatial distances among stands (r=0.82, P<0.05). We used the genetic reference database and Bayesian assignment testing to determine the geographic origins of two sets of mahogany wood samples, based on their multilocus genotypes. In both cases the wood samples were assigned to the correct country of origin. We discuss the overall applicability of this methodology to tropical timber trading.
Collapse
Affiliation(s)
- B Degen
- Johann Heinrich von Thünen-Institut, Institut für Forstgenetik, Sieker Landstrasse 2, D-22927 Grosshansdorf, Germany.
| | | | | | | | | | | |
Collapse
|
39
|
Song MK, Ward SE, Lin FC. End-of-life decision-making confidence in surrogates of African-American dialysis patients is overly optimistic. J Palliat Med 2012; 15:412-7. [PMID: 22468770 DOI: 10.1089/jpm.2011.0330] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Recent studies suggest that surrogate decision makers may be too optimistic about their end-of-life decision making abilities for loved ones. We examined surrogates' decision making confidence with an emphasis on its linkages to their understandings of patients' values and goals for end-of-life care. METHODS We used baseline data from a randomized trial with 58 dyads of African-American dialysis patients and their surrogates who separately completed the Values of Life-Sustaining Treatment Outcomes and the Goals of Care documents. Surrogates also completed a Surrogate Decision Making Confidence Scale. RESULTS Overall, 60% of surrogates were unsure how their loved ones would feel about continuing life-sustaining treatment, including dialysis, in at least one of the four outcomes presented in the Values of Life-Sustaining Treatment Outcomes. For goals of care near end of life, 67.2% to 69.0% of patients preferred comfort care only, but only 20 (34.5%) surrogates were congruent with patients on Goals of Care. Nonetheless, surrogates' confidence was high (M=3.23 out of 4.0). Surrogates' confidence was positively associated with dyad congruence in values for life-sustaining treatment at only a small magnitude (Spearman's rho=.31, p=.02), but not with dyad congruence in goals of care (χ(2)=2.13, df=1, p=.19). CONCLUSIONS Surrogates' confidence had little association with their actual understanding of patients' values and goals. Interventions to prepare patients and surrogates for end-of-life decision making may need to address overconfidence and help surrogates recognize their limited understanding of patients' values and goals.
Collapse
Affiliation(s)
- Mi-Kyung Song
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
| | | | | |
Collapse
|
40
|
Song MK, Ward SE, Hanson LC, Lin FC, Hamilton JB, Hladik G, Fine JP, Bridgman JC, Sun SK, Miles MS. Psychological symptoms and end-of-life decision making confidencein surrogate decision-makers of dialysis patients. J Nephrol Soc Work 2012; 36:A3. [PMID: 25242897 PMCID: PMC4169048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
This cross-sectional descriptive study explored surrogate decision-makers' psychological symptoms and their own assessment of decision-making abilities before actual involvement in end-of-life decision-making for their loved ones. One hundred-twenty dialysis patients' surrogates (79 African Americans and 41 Caucasians) completed scales measuring decision-making confidence, anxiety and depression, Post-Traumatic Symptoms (PTSS), and a sociodemographic questionnaire. Forty-two (35%) and 14 (11.7%) surrogates showed abnormal scores on anxiety and depression, respectively. Seven (5.8%) surrogates showed abnormal scores on PTSS. While surrogates decision making confidence was high (M=17.70, SD=2.88), there was no association between decision-making confidence and the three psychological variables. Surrogates' confidence was associated only with the quality of relationship with patient (r=0.33, p=0.001).
Collapse
Affiliation(s)
- Mi-Kyung Song
- School of Nursing, University of North Carolina at Chapel Hill
| | | | - Laura C. Hanson
- Division of Geriatric Medicine, Palliative Care Program, School of Medicine, University of North Carolina at Chapel Hill
| | - Feng-Chang Lin
- Department of Biostatistics, School of Public Health, University of North Carolina at Chapel Hill
| | | | - Gerald Hladik
- Division of Nephrology and Hypertension, School of Medicine, University of North Carolina at Chapel Hill
| | - Jason P. Fine
- Department of Biostatistics, School of Public Health, University of North Carolina at Chapel Hill
| | | | - Summer K. Sun
- School of Nursing, University of North Carolina at Chapel Hill
| | | |
Collapse
|
41
|
Cooper KL, Meng Y, Harnan S, Ward SE, Fitzgerald P, Papaioannou D, Wyld L, Ingram C, Wilkinson ID, Lorenz E. Positron emission tomography (PET) and magnetic resonance imaging (MRI) for the assessment of axillary lymph node metastases in early breast cancer: systematic review and economic evaluation. Health Technol Assess 2011; 15:iii-iv, 1-134. [PMID: 21276372 DOI: 10.3310/hta15040] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Breast cancer is the most common type of cancer in women. Evaluation of axillary lymph node metastases is important for breast cancer staging and treatment planning. OBJECTIVES To evaluate the diagnostic accuracy, cost-effectiveness and effect on patient outcomes of positron emission tomography (PET), with or without computed tomography (CT), and magnetic resonance imaging (MRI) in the evaluation of axillary lymph node metastases in patients with newly diagnosed early-stage breast cancer. DATA SOURCES A systematic review of literature and an economic evaluation were carried out. Key databases (including MEDLINE, EMBASE and nine others) plus research registers and conference proceedings were searched for relevant studies up to April 2009. A decision-analytical model was developed to determine cost-effectiveness in the UK. REVIEW METHODS One reviewer assessed titles and abstracts of studies identified by the search strategy, obtained the full text of relevant papers and screened them against inclusion criteria. Data from included studies were extracted by one reviewer using a standardised data extraction form and checked by a second reviewer. Discrepancies were resolved by discussion. Quality of included studies was assessed using the quality assessment of diagnostic accuracy studies (QUADAS) checklist, applied by one reviewer and checked by a second. RESULTS Forty-five citations relating to 35 studies were included in the clinical effectiveness review: 26 studies of PET and nine studies of MRI. Two studies were included in the cost-effectiveness review: one of PET and one of MRI. Of the seven studies evaluating PET/CT (n = 862), the mean sensitivity was 56% [95% confidence interval (CI) 44% to 67%] and mean specificity 96% (95% CI 90% to 99%). Of the 19 studies evaluating PET only (n = 1729), the mean sensitivity was 66% (95% CI 50% to 79%) and mean specificity 93% (95% CI 89% to 96%). PET performed less well for small metastases; the mean sensitivity was 11% (95% CI 5% to 22%) for micrometastases (≤ 2 mm; five studies; n = 63), and 57% (95% CI 47% to 66%) for macrometastases (> 2 mm; four studies; n = 111). The smallest metastatic nodes detected by PET measured 3 mm, while PET failed to detect some nodes measuring > 15 mm. Studies in which all patients were clinically node negative showed a trend towards lower sensitivity of PET compared with studies with a mixed population. Across five studies evaluating ultrasmall super-paramagnetic iron oxide (USPIO)-enhanced MRI (n = 93), the mean sensitivity was 98% (95% CI 61% to 100%) and mean specificity 96% (95% CI 72% to 100%). Across three studies of gadolinium-enhanced MRI (n = 187), the mean sensitivity was 88% (95% CI 78% to 94%) and mean specificity 73% (95% CI 63% to 81%). In the single study of in vivo proton magnetic resonance spectroscopy (n = 27), the sensitivity was 65% (95% CI 38% to 86%) and specificity 100% (95% CI 69% to 100%). USPIO-enhanced MRI showed a trend towards higher sensitivity and specificity than gadolinium-enhanced MRI. Results of the decision modelling suggest that the MRI replacement strategy is the most cost-effective strategy and dominates the baseline 4-node sampling (4-NS) and sentinel lymph node biopsy (SLNB) strategies in most sensitivity analyses undertaken. The PET replacement strategy is not as robust as the MRI replacement strategy, as its cost-effectiveness is significantly affected by the utility decrement for lymphoedema and the probability of relapse for false-negative (FN) patients. LIMITATIONS No included studies directly compared PET and MRI. CONCLUSIONS Studies demonstrated that PET and MRI have lower sensitivity and specificity than SLNB and 4-NS but are associated with fewer adverse events. Included studies indicated a significantly higher mean sensitivity for MRI than for PET, with USPIO-enhanced MRI providing the highest sensitivity. However, sensitivity and specificity of PET and MRI varied widely between studies, and MRI studies were relatively small and varied in their methods; therefore, results should be interpreted with caution. Decision modelling based on these results suggests that the most cost-effective strategy may be MRI rather than SLNB or 4-NS. This strategy reduces costs and increases quality-adjusted life-years (QALYs) because there are fewer adverse events for the majority of patients. However, this strategy leads to more FN cases at higher risk of cancer recurrence and more false- positive (FP) cases who would undergo unnecessary axillary lymph node dissection. Adding MRI prior to SLNB or 4-NS has little effect on QALYs, though this analysis is limited by lack of available data. Future research should include large, well-conducted studies of MRI, particularly using USPIO; data on the long-term impacts of lymphoedema on cost and patient utility; studies of the comparative effectiveness and cost-effectiveness of SLNB and 4-NS; and more robust UK cost data for 4-NS and SLNB as well as the cost of MRI and PET techniques. FUNDING This study was funded by the Health Technology Assessment programme of the National Institute of Health Research.
Collapse
Affiliation(s)
- K L Cooper
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Cooper KL, Meng Y, Harnan S, Ward SE, Fitzgerald P, Papaioannou D, Wyld L, Ingram C, Wilkinson ID, Lorenz E. Positron emission tomography (PET) and magnetic resonance imaging (MRI) for the assessment of axillary lymph node metastases in early breast cancer: systematic review and economic evaluation. Health Technol Assess 2011. [PMID: 21276372 DOI: 10.3310/hta15040.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Breast cancer is the most common type of cancer in women. Evaluation of axillary lymph node metastases is important for breast cancer staging and treatment planning. OBJECTIVES To evaluate the diagnostic accuracy, cost-effectiveness and effect on patient outcomes of positron emission tomography (PET), with or without computed tomography (CT), and magnetic resonance imaging (MRI) in the evaluation of axillary lymph node metastases in patients with newly diagnosed early-stage breast cancer. DATA SOURCES A systematic review of literature and an economic evaluation were carried out. Key databases (including MEDLINE, EMBASE and nine others) plus research registers and conference proceedings were searched for relevant studies up to April 2009. A decision-analytical model was developed to determine cost-effectiveness in the UK. REVIEW METHODS One reviewer assessed titles and abstracts of studies identified by the search strategy, obtained the full text of relevant papers and screened them against inclusion criteria. Data from included studies were extracted by one reviewer using a standardised data extraction form and checked by a second reviewer. Discrepancies were resolved by discussion. Quality of included studies was assessed using the quality assessment of diagnostic accuracy studies (QUADAS) checklist, applied by one reviewer and checked by a second. RESULTS Forty-five citations relating to 35 studies were included in the clinical effectiveness review: 26 studies of PET and nine studies of MRI. Two studies were included in the cost-effectiveness review: one of PET and one of MRI. Of the seven studies evaluating PET/CT (n = 862), the mean sensitivity was 56% [95% confidence interval (CI) 44% to 67%] and mean specificity 96% (95% CI 90% to 99%). Of the 19 studies evaluating PET only (n = 1729), the mean sensitivity was 66% (95% CI 50% to 79%) and mean specificity 93% (95% CI 89% to 96%). PET performed less well for small metastases; the mean sensitivity was 11% (95% CI 5% to 22%) for micrometastases (≤ 2 mm; five studies; n = 63), and 57% (95% CI 47% to 66%) for macrometastases (> 2 mm; four studies; n = 111). The smallest metastatic nodes detected by PET measured 3 mm, while PET failed to detect some nodes measuring > 15 mm. Studies in which all patients were clinically node negative showed a trend towards lower sensitivity of PET compared with studies with a mixed population. Across five studies evaluating ultrasmall super-paramagnetic iron oxide (USPIO)-enhanced MRI (n = 93), the mean sensitivity was 98% (95% CI 61% to 100%) and mean specificity 96% (95% CI 72% to 100%). Across three studies of gadolinium-enhanced MRI (n = 187), the mean sensitivity was 88% (95% CI 78% to 94%) and mean specificity 73% (95% CI 63% to 81%). In the single study of in vivo proton magnetic resonance spectroscopy (n = 27), the sensitivity was 65% (95% CI 38% to 86%) and specificity 100% (95% CI 69% to 100%). USPIO-enhanced MRI showed a trend towards higher sensitivity and specificity than gadolinium-enhanced MRI. Results of the decision modelling suggest that the MRI replacement strategy is the most cost-effective strategy and dominates the baseline 4-node sampling (4-NS) and sentinel lymph node biopsy (SLNB) strategies in most sensitivity analyses undertaken. The PET replacement strategy is not as robust as the MRI replacement strategy, as its cost-effectiveness is significantly affected by the utility decrement for lymphoedema and the probability of relapse for false-negative (FN) patients. LIMITATIONS No included studies directly compared PET and MRI. CONCLUSIONS Studies demonstrated that PET and MRI have lower sensitivity and specificity than SLNB and 4-NS but are associated with fewer adverse events. Included studies indicated a significantly higher mean sensitivity for MRI than for PET, with USPIO-enhanced MRI providing the highest sensitivity. However, sensitivity and specificity of PET and MRI varied widely between studies, and MRI studies were relatively small and varied in their methods; therefore, results should be interpreted with caution. Decision modelling based on these results suggests that the most cost-effective strategy may be MRI rather than SLNB or 4-NS. This strategy reduces costs and increases quality-adjusted life-years (QALYs) because there are fewer adverse events for the majority of patients. However, this strategy leads to more FN cases at higher risk of cancer recurrence and more false- positive (FP) cases who would undergo unnecessary axillary lymph node dissection. Adding MRI prior to SLNB or 4-NS has little effect on QALYs, though this analysis is limited by lack of available data. Future research should include large, well-conducted studies of MRI, particularly using USPIO; data on the long-term impacts of lymphoedema on cost and patient utility; studies of the comparative effectiveness and cost-effectiveness of SLNB and 4-NS; and more robust UK cost data for 4-NS and SLNB as well as the cost of MRI and PET techniques. FUNDING This study was funded by the Health Technology Assessment programme of the National Institute of Health Research.
Collapse
Affiliation(s)
- K L Cooper
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Drwecki BB, Moore CF, Ward SE, Prkachin KM. Reducing racial disparities in pain treatment: The role of empathy and perspective-taking. Pain 2011; 152:1001-1006. [DOI: 10.1016/j.pain.2010.12.005] [Citation(s) in RCA: 176] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Revised: 11/04/2010] [Accepted: 12/02/2010] [Indexed: 12/30/2022]
|
44
|
Ara R, Pandor A, Stevens J, Rafia R, Ward SE, Rees A, Durrington PN, Reynolds TM, Wierzbicki AS, Stevenson M. Prescribing high-dose lipid-lowering therapy early to avoid subsequent cardiovascular events: is this a cost-effective strategy? Eur J Prev Cardiol 2011; 19:474-83. [PMID: 21460076 DOI: 10.1177/1741826711406616] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND While evidence shows high-dose statins reduce cardiovascular events compared with moderate doses in individuals with acute coronary syndrome (ACS), many primary care trusts (PCT) advocate the use of generic simvastatin 40 mg/day for these patients. METHODS AND RESULTS Data from 28 RCTs were synthesized using a mixed treatment comparison model. A Markov model was used to evaluate the cost-effectiveness of treatments taking into account adherence and the likely reduction in cost for atorvastatin when the patent expires. There is a clear dose-response: rosuvastatin 40 mg/day produces the greatest reduction in low-density lipoprotein cholesterol (56%) followed by atorvastatin 80 mg/day (52%), and simvastatin 40 mg/day (37%). Using a threshold of £20,000 per QALY, if adherence levels in general practice are similar to those observed in RCTs, all three higher dose statins would be considered cost-effective compared to simvastatin 40 mg/day. Using the net benefits of the treatments, rosuvastatin 40 mg/day is estimated to be the most cost-effective alternative. If the cost of atorvastatin reduces in line with that observed for simvastatin, atorvastatin 80 mg/day is estimated to be the most cost-effective alternative. CONCLUSION Our analyses show that current PCT policies intended to minimize primary care drug acquisition costs result in suboptimal care.
Collapse
Affiliation(s)
- R Ara
- School of Health & Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, UK.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Gunnarsdottir S, Ward SE, Serlin RC. A population based study of the prevalence of pain in Iceland. Scand J Pain 2010; 1:151-157. [DOI: 10.1016/j.sjpain.2010.05.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Accepted: 05/05/2010] [Indexed: 10/19/2022]
Abstract
Abstract
Prevalence estimates of pain differ depending on how it is defined and measured and on the populations studied. It has been estimated that on a given day, as many as 30–44% of the general population experience some kind of pain. Information about the prevalence of pain in Iceland is not available. The aims of this study were to evaluate the prevalence of pain of various origins among the general population of Iceland, to test hypotheses regarding relationships between pain, quality of life (QOL) and demographic variables, to evaluate participants’ beliefs about causes of their pain, and to evaluate how those who experience pain manage it. A random sample of 1286 adults was drawn from a national registry holding information about all citizens of Iceland. Data were collected with a postal-survey. Pain was evaluated with the Brief Pain Inventory (BPI), with instructions modified to evaluate pain in the past week as opposed to the past 24 h. Of 1286 invited, 599 (46.6%) participated, of which, 232 had experienced pain in the past week (40.3%). Participants had a mean (SD) age of 44.94 (17.12) years and 56% were women. Those who had pain perceived their health to be worse than those who had not [B = −0.91, SE = 0.15, Wald = 38.75, p = 0.00], but did not differ on other variables. Of 232 individuals reporting pain, 183 (79.6%) or 30.6% of the total sample had experienced pain for more than three months. On a scale from 0 “no pain” to 10 “pain as bad as I can imagine” the mean (SD) pain severity score (composite of four pain severity scores) for the 232 participants reporting pain was 3.21 (1.73) and pain interference with life activities 2.59 (1.98), also on a 0–10 scale. Pain severity predicted pain interference [B = 0.71; F = 126.14; df = 1,206; p = 0.00], which mediated the effects of pain severity on mood and QOL. Between Pain Interference with Life and Positive Affect [B = −0.06; F = 4.53; df = 1,196; p = 0.04], between Pain Interference and Negative Affect [B = 0.15; F = 23.21; df = 1,196; p = 0.00], and between Pain Interference and Global Quality of Life [B = −0.18; F = 29.11; df = 1,196; p = 0.00]. Most frequent causes for pain were strain injuries (n = 79), resulting from work or sports activity, arthritis (n = 39), mechanical problems (e.g. due to birth defects, curvature, slipped discs, etc.) (n = 37), various diseases (n = 31) and accidents (n = 30). Nineteen participants did not know what caused their pain. Treatments for pain varied, but most had used medications alone (n = 76) or in combination with other treatments (n = 61). The prevalence of pain in the general population of Icelandic adults is similar to what has been reported. Estimates of chronic pain are towards the higher end when compared to data from other European counties, yet comparable to countries such as Norway. This raises questions about possible explanations to be looked for in genetics or cultural point of view. This population based study provides valuable information about the prevalence of pain in Iceland and also supports findings previously reported about pain in the neighboring countries.
Collapse
Affiliation(s)
- Sigridur Gunnarsdottir
- Landsptali National University Hospital of Iceland, Faculty of Nursing , Eiriksgata 34, 101 Reykjavik , Iceland
- National Hospital , Reykjavik , Iceland
| | - Sandra E. Ward
- University of Wisconsin Madison, School of Nursing , Wisconsin , United States
| | - Ronald C. Serlin
- University of Wisconsin Madison , Department of Educational Psychology , Wisconsin , United States
| |
Collapse
|
46
|
Malagodi EF, Gardner ML, Ward SE, Magyar RL. Responding maintained under intermittent schedules of electric-shock presentation: "Safety" or schedule effects? J Exp Anal Behav 2010; 36:171-90. [PMID: 16812238 PMCID: PMC1333066 DOI: 10.1901/jeab.1981.36-171] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Four experiments were conducted in which lever pressing by squirrel monkeys was maintained under multiple, mixed, or chained schedules of electric-shock presentation. In the first two experiments, a multiple schedule was employed in which a fixed-interval schedule of shock presentation alternated with a signaled two-minute component. Initially, no events were scheduled during the two-minute component (a safety period). In the first experiment, the safety period was "degraded" by introducing and systematically increasing the frequency of periodic shocks presented during that component. In the second experiment, the proportion of overall safe time to unsafe time was decreased by decreasing the value of the fixed-interval schedule while holding constant shock frequency during the two-minute component. In the third experiment, the overall arrangement was changed from a multiple to a mixed schedule in an attempt to determine whether fixed-interval responding would be maintained when a single exteroceptive stimulus was associated with both components. In the fourth experiment, the overall arrangement was changed from a multiple to a chained schedule in an effort to determine whether fixed-interval responding would be maintained when its consequence was presentation of a signaled "unsafe" period. Fixed-interval responding was well maintained under all experimental conditions; the varied relationships obtained lend more support to conceptualizations of shock-maintained behavior as exemplifying schedule-controlled behavior than to suggestions that such behavior may be readily accounted for by "safety theory."
Collapse
|
47
|
Song MK, Donovan HS, Piraino BM, Choi J, Bernardini J, Verosky D, Ward SE. Effects of an intervention to improve communication about end-of-life care among African Americans with chronic kidney disease. Appl Nurs Res 2010; 23:65-72. [DOI: 10.1016/j.apnr.2008.05.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Revised: 05/02/2008] [Accepted: 05/09/2008] [Indexed: 10/21/2022]
|
48
|
Ward SE, Serlin RC, Donovan HS, Ameringer SW, Hughes S, Pe-Romashko K, Wang KK. A randomized trial of a representational intervention for cancer pain: does targeting the dyad make a difference? Health Psychol 2009; 28:588-597. [PMID: 19751085 DOI: 10.1037/a0015216] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To determine the efficacy in overcoming attitudinal barriers to reporting cancer pain and using analgesics of an educational intervention presented to patients accompanied by a significant other (SO) as compared with patients alone. DESIGN Patient-SO pairs (N = 161) were randomized to the dyad condition (patient and SO received the intervention), solo condition (patient received the intervention), or care as usual. Dyad and solo conditions received the intervention at baseline (T1) and 2 and 4 weeks later. MAIN OUTCOME MEASURES Patients' and SOs' attitudes about analgesic use and patients' pain outcomes (pain severity, pain relief, interference with life, negative mood, and global quality of life [QOL]) at T1, 5 weeks later (T2), and 9 weeks later (T3). RESULTS Completers' analyses revealed no significant differences between groups at T2. At T3, patients in the dyad and the solo groups showed greater decreases in attitudinal barriers as compared with controls. T1-T3 changes in patients' barriers mediated between the dyad and solo interventions and pain severity, pain relief, pain interference, negative mood, and global QOL. CONCLUSION The intervention was no more efficacious when it was presented to dyads than to patients alone. Conditions under which SOs should be included in interventions need to be determined.
Collapse
|
49
|
Abstract
Randomized clinical trials support the efficacy of a wide range of psychoeducational interventions. However, the mechanisms through which these interventions improve outcomes are not always clear. At times, the theoretically specified factors within interventions have been shown to have specific effects on patient outcomes. But it has also been argued that other factors not identified in the intervention theory (e.g., "nonspecific" factors such as patient expectations and therapeutic patient-clinician alliances) have powerful nonspecific effects that account for most, if not all, of the observed efficacy of psychoeducational interventions. This article describes important concepts in this debate and discusses key issues in distinguishing between specific and nonspecific effects of psychoeducational nursing interventions. Four examples are used to illustrate potential methods of identifying and controlling for nonspecific effects in clinical intervention trials.
Collapse
|
50
|
Heidrich SM, Brown RL, Egan JJ, Perez OA, Phelan CH, Yeom H, Ward SE. An individualized representational intervention to improve symptom management (IRIS) in older breast cancer survivors: three pilot studies. Oncol Nurs Forum 2009; 36:E133-43. [PMID: 19403441 DOI: 10.1188/09.onf.e133-e143] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE/OBJECTIVES To test the feasibility and acceptability of an individualized representational intervention to improve symptom management (IRIS) in older breast cancer survivors and test the short-term effects of an IRIS on symptom distress. DESIGN Two small randomized clinical trials and one pre-experimental study. SETTING Oncology clinic and community. SAMPLE 41 women with breast cancer (aged 65 years and older) in pilot study 1, 20 in pilot study 2, and 21 in pilot study 3. METHODS In pilot study 1, women were randomized to the IRIS or usual care control. In pilot study 2, women were randomized to the IRIS or delayed IRIS (wait list) control. In pilot study 3, all women received the IRIS by telephone. Measures were collected at baseline, postintervention, and follow-up (up to four months). MAIN RESEARCH VARIABLES Feasibility, acceptability, symptom distress, symptom management behaviors, symptom management barriers, and quality of life. FINDINGS Across three pilot studies, 76% of eligible women participated, 95% completed the study, 88% reported the study was helpful, and 91% were satisfied with the study. Some measures of symptom distress decreased significantly after the IRIS, but quality of life was stable. Women in the IRIS group changed their symptom management behaviors more than controls. CONCLUSIONS Preliminary evidence supports the need for and feasibility of an IRIS. IMPLICATIONS FOR NURSING Nurses may help older breast cancer survivors manage their numerous chronic symptoms more effectively by assessing women's beliefs about their symptoms and their current symptom management strategies.
Collapse
|