Personalized symptom management: a quality improvement collaborative for implementation of patient reported outcomes (PROs) in 'real-world' oncology multisite practices.

BACKGROUND: Little research has focused on implementation of electronic Patient Reported Outcomes (e-PROs) for meaningful use in patient management in 'real-world' oncology practices. Our quality improvement collaborative used multi-faceted implementation strategies including audit and feedback, disease-site champions and practice coaching, core training of clinicians in a person-centered clinical method for use of e-PROs in shared treatment planning and patient activation, ongoing educational outreach and shared collaborative learnings to facilitate integration of e-PROs data in multi-sites in Ontario and Quebec, Canada for personalized management of generic and targeted symptoms of pain, fatigue, and emotional distress (depression, anxiety). PATIENTS AND METHODS: We used a mixed-methods (qualitative and quantitative data) program evaluation design to assess process/implementation outcomes including e-PROs completion rates, acceptability/use from the perspective of patients/clinicians, and patient experience (surveys, qualitative focus groups). We secondarily explored impact on symptom severity, patient activation and healthcare utilization (Ontario sites only) comparing a pre/post population cohort not exposed/exposed to our implementation intervention using Mann Whitney U tests. We hypothesized that the iPEHOC intervention would result in a reduction in symptom severity, healthcare utilization, and higher patient activation. We also identified key implementation strategies that sites perceived as most valuable to uptake and any barriers. RESULTS: Over 6000 patients completed e-PROs, with sites reaching 51%-95% population completion rates depending on initial readiness. e-PROs were acceptable to patients for communicating symptoms (76%) and by clinicians for treatment planning (80%). Patient experience was better than the provincial average. Compared to the pre-population, we observed a significant reduction in levels of anxiety (p = 0.008), higher levels of patient activation (p = 0.045), and reduced hospitalization rates (12.3% not exposed vs 10.1% exposed, p = 0.034). A pre/post population trend towards significance for reduced emergency department visit rates (14.8% not exposed vs 12.8% exposed, p = 0.081) was also noted. CONCLUSION: This large-scale pragmatic quality improvement project demonstrates the impact of implementation strategies and a collaborative improvement approach on acceptability of using PROs in clinical practice and their potential for reducing anxiety and healthcare utilization; and improving patient experience and patient activation when implemented in 'real-world' multi-site oncology practices.

Managing chemotherapy-related toxicities in the community setting: A survey of pharmacists in Ontario.

BACKGROUND: Toxicity management is a challenge with cancer treatment, including oral anticancer drugs. A review of claims data showed that a majority of publically funded oral anticancer drugs were filled in the community where pharmacists may not necessarily possess the specialized knowledge, skills, and experience required to provide effective patient care. A survey of community pharmacists in Ontario was conducted to identify the behaviours and preferences of community pharmacists specific to the management of treatment-related toxicities in order to standardize cancer care in this area. METHODS: An electronic questionnaire was distributed to approximately 5000 community pharmacists. The 21-question survey gathered information on the demographic profile of the pharmacists, basic geographic and socioeconomic variables associated with their practice setting, current toxicity management practices, education and training needs, and preferences for communicating with other providers. RESULTS: Of 349 pharmacists, almost all (94.9%) were interested in managing chemotherapy-related toxicities as part of their work, but the majority (77.1%) did not feel that their current level of pharmacy training has provided them with an oncology education sufficient for the demands of their practice. Approximately 52% of respondents indicated that they have reached out to the health care provider at a cancer centre, and of those, 72.7% reported that their questions were resolved within 48 h. More than half of all survey respondents (53.9%) indicated that they would prefer to receive a response within 12 h from cancer centres. CONCLUSIONS: The results of this study support the need to provide community pharmacists with oncology-specific training and timely correspondences from providers at prescribing institutions in order to manage toxicities.

Effect of PET/CT on the Management and Outcomes of Participants with Hodgkin and Aggressive Non-Hodgkin Lymphoma: A Multicenter Registry.

Purpose To determine the relationship of PET/CT staging to the management and outcomes of participants with apparent limited-stage (LS) Hodgkin lymphoma (HL) or aggressive non-HL (ANHL) treated with curative intent. Materials and Methods This prospective multicenter registry included 850 participants (467 men and 383 women; median age, 54.1 years) from nine centers who had LS HL or ANHL on the basis of clinical data and CT, or with equivocal CT for advanced stage, who were considered for curative-intent first-line therapy. Participants were recruited between May 1, 2013, and December 31, 2015. Pre-PET/CT treatment plan was compared with treatment provided. Survival and second-line therapy initiation were compared with an historical control pool staged by using CT alone. Administrative data sources were used to control for baseline characteristics. Outcomes were assessed by using adjusted Cox proportional hazards regression and propensity score matching. Results PET/CT helped to upstage 150 of 850 participants (17.6%). There was a change in planned therapy in 224 of 580 (38.6%) of participants after PET/CT. There was a lower 1-year mortality for participants with ANHL in the PET/CT versus CT cohort (hazard ratio, 0.63; 95% confidence interval: 0.40, 1.0; P < .05) and for those with LS at PET/CT compared with those with LS at CT (hazard ratio, 0.40; 95% confidence interval: 0.21, 0.74; P = .004). For participants with HL, no 1-year outcome difference was found (P = .16). Conclusion PET/CT helped to upstage approximately 18% of participants and planned management was frequently altered. Participants with aggressive non-Hodgkin lymphoma whose first-line therapy was guided by PET/CT had significantly better survival compared with participants whose treatment was guided by CT. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Scott in this issue.

Modeling Reference Production as the Probabilistic Combination of Multiple Perspectives.

While speakers have been shown to adapt to the knowledge state of their addressee in choosing referring expressions, they often also show some egocentric tendencies. The current paper aims to provide an explanation for this "mixed" behavior by presenting a model that derives such patterns from the probabilistic combination of both the speaker's and the addressee's perspectives. To test our model, we conducted a language production experiment, in which participants had to refer to objects in a context that also included a visually misleading object (e.g., a crayon shaped like a Lego brick) whose function was either known to both partners, or known just to the speaker but not the addressee. Modeling results indicate that the experimental findings cannot be explained by assuming that speakers tailor a referring expression solely to their own perspective or to the perspective of their addressee. Instead, accounting for the behavioral pattern requires an approach where both perspectives influence the choice of referring expressions. Nevertheless, in our situation, speakers consider their partner's perspective more than their own.

Verbal Ability, Argument Order, and Attitude Formation.

The current study explored the interaction of verbal ability and presentation order on readers' attitude formation when presented with two-sided arguments. Participants read arguments for and against compulsory voting and genetic engineering, and attitudes were assessed before and after reading the passages. Participants' verbal ability was measured, combining vocabulary knowledge and reading comprehension skill. Results suggested that low verbal-ability participants were more persuaded by the most recent set of arguments whereas high verbal-ability participants formed attitudes independent of presentation order. Contrary to previous literature, individual differences in the personality trait need for cognition did not interact with presentation order. The results suggest that verbal ability is an important moderator of the effect of presentation order when formulating opinions from complex prose.

Privileged versus shared knowledge about object identity in real-time referential processing.

A central claim in research on interactive conversation is that listeners use the knowledge assumed to be shared with a conversational partner to guide their understanding of utterances from the earliest moments of processing. In the present study we investigated whether this claim extends to cases where shared vs. private knowledge is discrepant in terms of the identity assigned to a mutually seen object that could be misidentified on the basis of its appearance. Eye movement measures were used to evaluate listeners' ability to integrate a speaker's perspective as they identified the referent for an unfolding expression. The results reconfirmed previous findings showing that listeners can rapidly take into account a speaker's awareness of the existence/presence of a referential object. In contrast, however, listeners showed strong consideration of their private knowledge about the identity of an object during referential processing. Strikingly, this tendency was found even when speaker-produced discourse reinforced the way in which the speaker's understanding of the object's identity differed from that of the listener. Together, the results reveal clear and important differences in the way in which distinct types of perspective-based cues are integrated in real-time communicative interaction.

A cautionary note on the use of the Analysis of Covariance (ANCOVA) in classification designs with and without within-subject factors.

A number of statistical textbooks recommend using an analysis of covariance (ANCOVA) to control for the effects of extraneous factors that might influence the dependent measure of interest. However, it is not generally recognized that serious problems of interpretation can arise when the design contains comparisons of participants sampled from different populations (classification designs). Designs that include a comparison of younger and older adults, or a comparison of musicians and non-musicians are examples of classification designs. In such cases, estimates of differences among groups can be contaminated by differences in the covariate population means across groups. A second problem of interpretation will arise if the experimenter fails to center the covariate measures (subtracting the mean covariate score from each covariate score) whenever the design contains within-subject factors. Unless the covariate measures on the participants are centered, estimates of within-subject factors are distorted, and significant increases in Type I error rates, and/or losses in power can occur when evaluating the effects of within-subject factors. This paper: (1) alerts potential users of ANCOVA of the need to center the covariate measures when the design contains within-subject factors, and (2) indicates how they can avoid biases when one cannot assume that the expected value of the covariate measure is the same for all of the groups in a classification design.