Turning Psychosocial Screening Into Outcomes

TON - August 2011 VOL 4, NO 5 — August 24, 2011

CHICAGO—Both patients and practitioners realize the importance of psychosocial issues, but today’s cancer care often fails to address them. Steps to resolve this problem are under way, according to experts at an education session.

Standards for assessing psychosocial concerns were included in the American Society of Clinical Oncology (ASCO)/Oncology Nursing Society Chemo therapy Administration Safety Standards released in 2009. And beginning in 2012, psychosocial distress screening will be a required standard for American College of Surgeons Com mission on Cancer accreditation. In clusion of psychosocial concerns in these standards will likely increase awareness and assessment of patients’ needs; but how to translate screening into outcomes?

“We need to assist practices seeking to improve psychosocial care,” said Paul B. Jacobsen, PhD, chair, Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida. To do that, his group examined the quality indicators in psychosocial care, seeking to determine if clinician improvement in performance indicators enhances pa tients’ quality of life.

Where We Are

The team began by developing methods to identify quality indicators from medical records. They reviewed more than 1600 cases of colorectal, breast, and non–small-cell lung cancer treated in 2006 at 11 cancer centers in Florida. Presenting their findings, Jacobsen detailed the indicators.

  • Evidence in the medical chart that current emotional well-being was assessed within 1 month of the first visit with a medical oncologist. This could include a copy of a distress, depression, or anxiety screening measure; a copy of a form indicating a patient selfreport; or a note using any one of the terms coping, adjustment, emotional distress, depression, or anxiety in reference to patient status.
  • If a problem with emotional well-being was identified, evidence action was taken to address the problem or an explanation provided for no action being taken. This could include care provided by the primary oncology team, referral to another professional, or a note describing why no action was taken.

Their findings suggest that making practitioners aware of their shortcomings can improve the rate of psycho - social screening. This does not hold true, however, for increasing the rate of action.

For assessing emotional well-being, performance ranged widely among the 11 practices, from 12% to 86% (overall rate, 46%). For action taken, performance ranged even wider, from 13% to 100% (overall rate, 53%). For perspective, Jacobsen noted that “these same practices rated between 55% and 97% for assessing pain (overall rate, 85%).”

In fall 2008, ASCO’s Quality Oncology Practice Initiative (QOPI) adopted Jacobsen and colleagues’ indicators for psychosocial care, which provided the team information from 166 practices. In comparing these data from fall 2008 with fall 2009, they found assessment rates to range from 64% to 73%. This represents a substantial increase over the 1-year period compared with nonpsychosocial QOPI indicators. The high rate of increase suggests that feedback works well for increasing assessment, according to Jacobsen. For action taken, however, the rate increased only slightly, from 74% to 78%. Jacobsen noted that this small increase suggests that feedback alone is not going to solve this issue.

Where We Can Go

“A treatment model that engages frontline cancer care practitioners and provides support resources as well as guidance can make a difference,” said David Goldstein, MBBS, FRACP, FRCP (UK), Department of Medical Oncology, Prince of Wales Hospital, New South Wales, Australia, who presented a model that “systematically introduces multidisciplinary care of the psychosocial needs of patients with cancer, [which] can be a reality in a practice of any size.”

Studies in oncology practices have shown that screening is feasible, but often does not lead to improvement in psychosocial care or quality of life, according to Goldstein. Studies outside of oncology, however, have presented models that can help (Unutzer J, et al. JAMA. 2002;288:2836-2845; Katon WJ, et al. N Engl J Med. 2010;363:2611- 2620).

By adapting these models, cancer centers have achieved success. Goldstein detailed a model that uses nurses, nurse practitioners, and/or physician assistants as care managers. Although each pilot study used slightly different intervention designs, all of them had key components in common:

  • Frontline cancer care practitioners act as care managers.
  • These frontline oncology health professionals, who are trained in oncology first, receive additional mental health training.
  • A small number of mental health professionals supply support and manage the intervention.

Forms of this model enhanced quality of life in elderly patients with depression and cancer (50% vs 34% reduction in symptoms at 6 months; 39% vs 20% reduction at 12 months; Fann JR, et al. J Gen Intern Med. 2009;24[suppl 2]: S417-S424) and in patients with major depressive disorder being treated as outpatients in a large UK cancer center (53% vs 34% reduction in depression; 68% vs 45% remission rate; Strong V, et al. Lancet. 2008;372:40-48).

In addition, adapting the model for regional and rural practices produced similar results by using remote care managers. Using a telephone-based service, nurse care managers increased the percentage of patients who responded to treatment for cancer-related depression (33.7% vs 27.9% at 12 months) as well as reduced the percentage of incidences of depressive episodes (from 61% to 21.4% in the intervention group vs from 61.9% to 35.2% in the usual care group; Kroenke K, et al. JAMA. 2010;304:163-171).

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