Impact of a telehealth intervention on quality of life and symptom distress in patients with head and neck cancer.

BACKGROUND: Patients undergoing treatment for head and neck cancer commonly experience signi•cant changes in quality of life (QoL) and levels of symptom distress. It is not known if a telehealth intervention would mitigate these changes. OBJECTIVE: To evaluate the impact of a telehealth intervention on QoL and symptom burden in patients undergoing initial treatment for head and neck cancers. METHODS: A randomized clinical trial comparing the impact on QoL and symptom distress of telehealth intervention and standard care was conducted with 80 patients (45 treatment, 35 control) who had been diagnosed with head or neck cancer and were receiving 1 or more treatment modalities. Treatment group participants responded daily to symptom management algorithms using a simple telehealth messaging device. QoL was evaluated by the Functional Assessment of Cancer Therapy-Head and Neck Scale (FACTHN) and symptom burden by the Memorial Symptom Assessment Scale (MSAS). Control group participants completed assessments while they received routine care. RESULTS: In the posttreatment phase, the telehealth participants had signi•cantly better scores than the controls for physical well-being (20.6 vs 17.0, P = .02) and trial outcome index (59.9 vs. 50.2, P = .04) on the FACT-HN, and total scores on the MSAS (0.9 vs. 1.2, P = .04). LIMITATIONS: The moderate sample size of 80 patients limits the power to measure more subtle impacts of the intervention. CONCLUSIONS: Using telehealth to provide support to patients with head and neck cancer during the acute phase of treatment improved some aspects of posttreatment QoL and symptom burden.

Use of the Distress Thermometer to discern clinically relevant quality of life differences in women with breast cancer.

PURPOSE: The purpose of this study was to explore the ability of Distress Thermometer (DT) scores to discern important differences in quality of life scores among women with breast cancer. METHODS: The National Comprehensive Cancer Network's DT, the Functional Assessment of Cancer Therapy-Breast (FACT-B), and a demographic questionnaire were completed by 111 women recently diagnosed with breast cancer. RESULTS: Patients considered moderately to severely distressed (score ≥ 4 on DT) scored significantly lower on FACT-B QOL scales and subscales when compared to those in the group scoring 3 or below. For those scales for which minimally important differences (MIDs) have been established, differences between the two groups were 2-3 and a half times the established MID. CONCLUSIONS: Moderately to severely distressed patients have significantly lower QOL than those with expected or mild distress. The DT provides a quick and easy screening tool to alert the healthcare team to clinically relevant alterations in patients' QOL.

Feasibility and Acceptance of a Telehealth Intervention to Promote Symptom Management during Treatment for Head and Neck Cancer.

Patients undergoing treatment for head and neck cancers have a myriad of distressing symptoms and treatment side effects which significantly alter communication and lower quality of life. Telehealth technology has demonstrated promise in improving patient-provider communication by delivering supportive educational content and guidance to patients in their homes. A telehealth intervention using a simple telemessaging device was developed to provide daily education, guidance, and encouragement for patients undergoing initial treatment of head and neck cancer. The goal of this article is to report the feasibility and acceptance of the intervention using both quantitative and qualitative measures. No eligible patients declined participation based on technology issues. Participants completed the intervention over 86% of the expected days of use. Direct nursing contact was seldom needed during the study period. Satisfaction with the technology and the intervention was very high. In this study a telehealth intervention was shown to be feasible, well accepted, and regularly used by patients experiencing extreme symptom burden and declining quality of life as a result of aggressive treatment for head and neck cancer.

The relationship between weight loss and health-related quality of life in persons treated for head and neck cancer.

PURPOSE: This study explores the relationship between weight loss, health-related quality of life (HRQOL), and symptom burden in patients treated for head and neck cancers. METHODS: Participants completed the Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N) and the Memorial Symptom Assessment Scale (MSAS) pre-treatment, mid-treatment, and post-treatment. Weights were recorded prior to treatment and at the post-treatment follow-up visit, and percentage weight loss was tabulated. Relationships between weight loss, HRQOL, and symptom burden were evaluated using the nonparametric Spearman rho. A simple linear regression model was developed to examine the influence weight loss has on HRQOL in a predictive manner. RESULTS: Average weight loss per patient was 12 lb with a modal value of 19. Weight loss was found to be significantly correlated with decreases in physical well-being, functional well-being, the Head and Neck specific subscale, and composite QOL scores. No significant correlations were found between weight loss and symptom burden as measured by the MSAS. Linear regression suggested that a 10% decrease in baseline weight resulted in a 19% decrease in the FACT-H&N score. CONCLUSION: The strong association between weight loss and HRQOL supports the importance of efforts to prevent weight loss via patient education, aggressive monitoring, and immediate intervention to stop or reverse weight loss during treatment. New approaches to the weight loss and wasting experienced by patients should be developed and tested.

Palliative care case management: increasing access to community-based palliative care for Medicaid recipients.

PURPOSE: The purpose of this pilot project was to integrate palliative care principles and practices into the day-to-day operations of a Medicaid managed care provider. This was accomplished through the following five activities: (1) employment of an experienced palliative care nurse and social worker to serve as expert role models and consultants to the case management staff; (2) development of a palliative care training curriculum for case managers; (3) provision and evaluation of the training; (4) identification of appropriate patients, provision of palliative care case management (PCCM), and tracking of outcomes; and (5) development of a resource/reference manual for case managers. PRIMARY PRACTICE SETTING: The project involved a managed care organization providing Medicaid services to patients residing in both urban and rural settings. FINDINGS/CONCLUSIONS: Expert staff was hired and modeled effective PCCM. This, as well as the training program, had significant influence on both the palliative care knowledge and attitudes of existing case managers. Involved patients demonstrated improved symptom management and satisfaction with care. Patient scenarios demonstrated desirable outcomes in healthcare utilization, and timely, appropriate hospice referrals were realized. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Integrating PCCM into the practices of a provider of Medicaid managed care can result in positive patient outcomes, improved utilization of healthcare services, and related savings for the managed care provider. Such a program can increase access to community-based palliative care for Medicaid recipients with life-threatening illnesses. PCCM can address the multiple needs of younger patients with serious illness who are not yet ready to forego curative efforts.

Development of a telehealth intervention for head and neck cancer patients.

Treatment for head and neck cancer precipitates a myriad of distressing symptoms. Patients may be isolated both physically and socially and may lack the self-efficacy to report problems and participate as partners in their care. The goal of this project was to design a telehealth intervention to address such isolation, develop patient self-efficacy, and improve symptom management during the treatment experience. Participatory action research and a review of the literature were used to develop electronically administered symptom management algorithms addressing all major symptoms experienced by patients undergoing treatment for head and neck cancers. Daily questions and related messages were then programmed into an easy-to-use telehealth messaging device, the Health Buddy(R). Clinician and patient acceptance, feasibility, and technology issues were measured. Using participatory action research is an effective means for developing electronic algorithms acceptable to both clinicians and patients. The use of a simple tele-messaging device as an adjunct to symptom management is feasible, affordable, and acceptable to patients. This telehealth intervention provides support and education to patients undergoing treatment for head and neck cancers.

Initiating and sustaining a standardized pain management program in long-term care facilities.

OBJECTIVES: To identify current pain management practices in the long-term care setting; and, implement and evaluate a comprehensive pain management program in the long-term care setting. DESIGN: An interventional pilot study. SETTING: Community-based long-term care facilities. METHODS: This study was conducted in two phases. Phase I consisted of interviewing long-term care facility administrators to ascertain current pain management policies and practices. This information was used to develop the Phase II intervention that involved collecting benchmark data, creating or modifying pain policies and procedures, implementing a pain management program and presenting educational programs. MEASUREMENTS: Interviews with long term care administrators; facility and resident demographic data; chart audits for pain assessment and management data; pharmacy audits; telephone surveys. RESULTS: Pain management policies and practices were inadequate prior to the study intervention. No facilities had policies or procedures that required ongoing (daily, weekly, etc.) pain assessment. Only one facility had mechanisms in place for measuring the presence or intensity of pain in their non-verbal, cognitively-impaired residents. Following the pain management program intervention, pain assessment significantly increased. and treatment for pain was provided for the vast majority of those indicating pain. All sites had a standardized pain assessment program in place one-year post-study completion. CONCLUSIONS: Standardized pain management programs are critical to improving pain management in long-term care settings. Improvement in long-term care pain management can be obtained through a comprehensive pain management program that involves staff education, changes in pain policies and procedures, and identifying pain management as a quality indicator.

The Caring Connections Project: Providing palliative care to Medicaid patients with advanced cancer.

Palliative care, with its focus on symptom management, patient-centered goals, preparation for life's end, and preservation of quality of life in the face of advancing illness, is a rapidly advancing component of mainstream American medicine. Yet, access to palliative care is often lacking in the community setting and may be further hindered by the presence of healthcare disparities that impact the poor. This article presents a unique approach to assuring the availability of palliative care to Medicaid patients receiving case management services. This descriptive article describes the evolution of a palliative care management pilot program, the Caring Connections Program, beginning with the initial planning and progressing through implementation and provision of services to 56 persons. "Lessons learned" are shared to enable other providers to develop similar programs with success. Patient profiles and intervention strategies are offered to illustrate the work accomplished.

Kentucky's palliative care report card.

Last Acts released the first nationwide evaluation of palliative care services in November 2002. Each state was evaluated or "graded" on the following eight measures: advance care planning policies, location of death, hospice use, hospital end-of-life care services, care in ICUs at the end of life, pain among nursing home residents, state pain policies, and palliative care certified physicians and nurses. Kentucky scored well on state pain policies and number of nurses certified in palliative care but received low grades for hospital services and the number of patient deaths occurring in the home. This manuscript explores Kentucky's deficiencies and accomplishments related to the Last Acts evaluation and addresses opportunities for improving end-of-life care across the Commonwealth.