Outcome Measures and Patient-Reported Metrics in Cancer Rehabilitation.

PURPOSE OF REVIEW: The current panorama of measurement tools for use in cancer rehabilitation is reviewed. For rehabilitation purposes, evaluating function is of the highest priority. RECENT FINDINGS: From a patient-reported outcome (PRO) standpoint, SF-36 and EORTC-QLQ-C30 are in most common use in cancer rehabilitation research; these are quality of life measures that contain functional subdomains. Newer tools which are based on item response theory and have options for both computer assisted or short form (SF) administration, including the Patient-Reported Outcomes Measurement Information System (PROMIS) and Activity Measure for Post-acute Care (AMPAC) instruments, show increasing use, especially PROMIS Physical Function SF, and, recently, PROMIS Cancer Function Brief 3D, which has been validated in the cancer population, with domains of physical function, fatigue, and social participation, to track clinical rehabilitation outcomes. Evaluating objective measures of function in cancer patients is also crucial. Utilization of clinically feasible tools for cancer rehabilitation, to employ for both screening purposes and for monitoring of rehabilitation treatment efficacy, is an evolving area, much needed to promote further research and improved, consistent clinical care for cancer patients and survivors.

Brain Tumors and Metastases.

Patients with brain tumor exhibit wide-ranging prognoses and functional implications of their disease and treatments. In general, the supportive care needs of patients with brain tumor, including disabling effects, have been recognized to be high. This review (1) briefly summarizes brain tumor types, treatments, and prognostic information for the rehabilitation clinician; (2) reviews evidence for rehabilitation, including acute inpatient rehabilitation and cognitive rehabilitation, and the approaches to selected common symptom and medical management issues; and (3) examines emerging data about survivorship, such as employment, community integration, and fitness.

Interdisciplinary Rehabilitation Referrals in a Concussion Clinic Cohort: An Exploratory Analysis.

OBJECTIVE: To assess the frequency and spectrum of referrals to rehabilitation disciplines in a concussion clinic population and factors associated with need for referral. DESIGN: Retrospective study. SETTING: Concussion clinic within the Physical Medicine and Rehabilitation Department of an academic medical center. PARTICIPANTS: Patients receiving physiatric management for concussion care. MAIN OUTCOME MEASURES: Referral to physical therapy (PT), occupational therapy, speech therapy (ST), neuropsychology, or any referral (Any), and reasons for referral. INTERVENTIONS: Demographic and clinical variables were analyzed for possible association with referral to rehabilitation disciplines. These independent variables included mechanism of injury, referral source, age, gender, provider, days since injury, presenting Sports Concussion Assessment Tool 2 (SCAT2) symptom score, insurance type, clinical risk factors, whether the injury was work related and whether the patient had been hospitalized. RESULTS: Among 262 patients meeting inclusion criteria, the most commonly prescribed individual therapy was physical therapy (74 patients; 28%), followed by speech therapy (60 patients, 23%), neuropsychology (27 patients, 10.3%), and occupational therapy (19 patients, 7.2%). In all, 121 (46%) of patients were referred to one or more disciplines. The most common reasons for referral were cognitive strategies (54 patients, 21%), balance/vestibular therapy (50 patients,19%), and neck pain (32 patients, 12%). Per multivariate logistic regression analysis, covariates associated with PT: age, SCAT2 symptom score, gender, provider, and (inversely) cognitive/learning disorder; ST: time elapsed since injury, gender, and referral source of internal clinic; Any: SCAT2 symptom score. Referrals did not significantly vary by mechanism of injury (sports, fall, vehicular, etc), whether work-related, or whether the patient had been hospitalized. Insurance factors were significant for PT and Any on the univariate analysis but not logistic regression. CONCLUSIONS: Relatively little has been described about the typical rehabilitation requirements of individuals recovering from concussion. Although rest and guided return to usual activities have been emphasized as mainstays of management, a large number of patients in this concussion cohort were determined to require additional rehabilitation services to assist in recovery.

National Institutes of Health Stroke Scale (NIHSS) as An Early Predictor of Poststroke Dysphagia.

BACKGROUND: Despite the availability of multiple comprehensive screening methods to detect dysphagia during acute stroke care, consensus is lacking as to the best practice. Our previous study demonstrated favorable sensitivity of the Functional Independence Measure (FIM) compared with a bedside 3-sip test. However, the FIM is challenging to administer during acute stroke care. The National Institutes of Health Stroke Scale (NIHSS) is administered routinely in the emergency department. OBJECTIVE: To evaluate the utility of the NIHSS as a predictor of clinically relevant poststroke dysphagia compared with FIM data in the same cohort. DESIGN: Retrospective analysis. SETTING: Academic medical center. PATIENTS: Individuals with acute stroke who were admitted for acute care and later transferred to acute rehabilitation within the same institution. METHODS: Clinically relevant dysphagia was defined as aspiration on modified barium swallow or laryngeal penetration on modified barium swallow requiring diet change, or aspiration pneumonia. NIHSS and FIM scores were compiled for all patients. MAIN OUTCOME MEASUREMENTS: Sensitivity, specificity, positive predictive value, and negative predictive value were calculated for NIHSS and FIM. Sensitivity and specificity of different values of NIHSS and FIM were analyzed via receiver operator characteristic curves. RESULTS: Of 290 patients admitted to acute stroke rehabilitation, 88 (30%) manifested clinically relevant dysphagia during their rehabilitation stay. Sensitivity analyses suggested cut-off values for the NIHSS and the FIM of >9 and <55, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value for the NIHSS were 75%, 62%, 46%, and 85%, respectively. For the FIM, these parameters were 80%, 72%, 55%, and 92%, respectively. CONCLUSIONS: The NIHSS >9 and FIM <55 are moderately predictive of clinically relevant dysphagia. Although the NIHSS clinical test characteristics are not as favorable as the FIM, NIHSS appears to be more sensitive than some other reported methods such as a 3-sip water test. Further study into development of paradigms that incorporate NIHSS into initial assessment of dysphagia risk may be appropriate.

Supportive care after curative treatment for breast cancer (survivorship care): resource allocations in low- and middle-income countries. A Breast Health Global Initiative 2013 consensus statement.

Breast cancer survivors may experience long-term treatment complications, must live with the risk of cancer recurrence, and often experience psychosocial complications that require supportive care services. In low- and middle-income settings, supportive care services are frequently limited, and program development for survivorship care and long-term follow-up has not been well addressed. As part of the 5th Breast Health Global Initiative (BHGI) Global Summit, an expert panel identified nine key resources recommended for appropriate survivorship care, and developed resource-stratified recommendations to illustrate how health systems can provide supportive care services for breast cancer survivors after curative treatment, using available resources. Key recommendations include health professional education that focuses on the management of physical and psychosocial long-term treatment complications. Patient education can help survivors transition from a provider-intense cancer treatment program to a post-treatment provider partnership and self-management program, and should include: education on recognizing disease recurrence or metastases; management of treatment-related sequelae, and psychosocial complications; and the importance of maintaining a healthy lifestyle. Increasing community awareness of survivorship issues was also identified as an important part of supportive care programs. Other recommendations include screening and management of psychosocial distress; management of long-term treatment-related complications including lymphedema, fatigue, insomnia, pain, and women's health issues; and monitoring survivors for recurrences or development of second primary malignancies. Where possible, breast cancer survivors should implement healthy lifestyle modifications, including physical activity, and maintain a healthy weight. Health professionals should provide well-documented patient care records that can follow a patient as they transition from active treatment to follow-up care.

Simplifying the 360-degree peer evaluation in a physical medicine and rehabilitation residency program.

OBJECTIVE: A previous study determined that multiple questions on a 360-degree evaluation instrument were highly correlated, suggesting possible redundancy in what was being measured, and that some questions may be eliminated. The current study uses factor analysis and examines a larger data set to further explore this question. DESIGN: To evaluate the structure of the questionnaire, a factor analysis was performed on 3 yrs of data from a 19-item resident 360-degree evaluation. The number of factors was determined by examining the scree plot of eigenvalues for each item in the instrument, with a cutoff where the slope changes from rapid to slow decline. A reliability analysis was performed with the indicated number of factors, with deletion of each variable to evaluate its influence on overall reliability (Cronbach alpha). RESULTS: There were 299 evaluations with complete responses to all 19 questions. The scree plot supported a single factor model. The reliability of the full, single factor survey was excellent (Cronbach α = 0.99). The three items with the highest loading on the factor were retained, which related to humanistic, moral/ethical, and professional responsibility behaviors. The reliability for these final three items remained excellent (Cronbach α = 0.96). CONCLUSIONS: The factor analysis suggests that one overall opinion of the evaluated resident was informing the responses of the evaluator. Shortening the instrument to the three items responsible for the greatest influence on the survey does not result in a large decrease in reliability as measured by Cronbach alpha. It is possible that time limitations prevent residents from putting thought into the evaluation of their peers, which results in unidimensional responses. Shortening the instrument may improve evaluations and should be studied in the future.

Does a 3-sip test detect dysphagia in acute stroke rehabilitation patients?

OBJECTIVES: (1) Evaluate sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a 3-sip test within 24 hours of acute stroke as a screening for clinically relevant dysphagia during acute rehabilitation. (2) For those patients who pass the 3-sip test, identify factors predictive of later detection of clinically relevant dysphagia. DESIGN: A retrospective review. SETTING: Acute stroke rehabilitation unit of a tertiary academic medical center. PATIENTS: 223 patients undergoing dysphagia screening after stroke. MAIN OUTCOME MEASURE: Development of clinically relevant dysphagia. RESULTS: Seventeen of 223 patients (7.6%) failed the 3-sip test. Of the 206 patients who passed the 3-sip test, 57 (27.7%) manifested clinically relevant dysphagia. Sensitivity and specificity of the 3-sip test were 20.8% and 98.7%, respectively. PPV and NPV were 88.2% and 72.3%, respectively. Among those who passed the 3-sip test, logistic regression identified the Functional Independence Measure (FIM) total score as the only independent predictor (B = -0.066, P < .001) of clinically relevant dysphagia. Of those patients who passed the 3-sip test, 54.6% with an FIM total score <60 had clinically relevant dysphagia compared with 11.9% with an FIM total score >60. CONCLUSIONS: The sensitivity of the 3-sip test was poor for stroke rehabilitation patients. For those who passed the 3-sip test, a low FIM total score was predictive of development of clinically relevant dysphagia. A high degree of clinical suspicion for dysphagia should remain after passing a 3-sip screening test, especially for those with FIM total score <60.

Inpatient cancer rehabilitation: a retrospective comparison of transfer back to acute care between patients with neoplasm and other rehabilitation patients.

OBJECTIVE: To determine whether patients with diagnoses of neoplasm undergoing acute rehabilitation differ from other patients in frequency of acute care transfer and type of medical complications. DESIGN: Retrospective cohort analysis. SETTING: Acute rehabilitation hospital located within an academic medical center. PARTICIPANTS: Patients with diagnosis of neoplasm (n=40) and patients without neoplasm (n=253) requiring transfer were identified from a database of 2801 rehabilitation discharges over nearly a 4-year period. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Frequency of unplanned transfer and reasons for the transfer. RESULTS: Significant difference occurred in overall rate of transfer between patients with neoplasm (21%) and controls (9.7%; P<.001). When evaluated separately for type of neoplasm (with patients receiving corresponding type of rehabilitation as controls), a significantly higher rate of transfer to acute care was found for brain tumor (25% vs 12%; P=.004) and spinal cord neoplasms (23% vs 10%; P=.009), but statistical significance was not reached for other tumor types (12.5% vs 7.4%; P=.19). Patients with stroke with neoplasm as a comorbidity, analyzed separately, with the other patients with stroke as controls, had significantly higher risk of transfer (22% vs 10%; P=.012). Logistic regression analysis found an odds ratio (OR) of 2.5 for unplanned transfer among patients with diagnosis of neoplasm (OR=2.5 for malignancy; OR=2.4 for benign neoplasm). Patients with neoplasm had infection as the most common reason for transfer (28% of the neoplasm transfers vs 18% of other transfers; P=.01), whereas in the nonneoplasm group, cardiopulmonary factors predominated (12% of patients with tumor vs 31% of patients without tumor transfers; P<.001). CONCLUSIONS: In the present sample, patients with neoplasm were more likely to require transfer than patients without neoplasm, although this pattern did not reach statistical significance for noncentral nervous system cases. Overall, patients with neoplasm appear more likely than those without neoplasm to have an infectious cause for unplanned transfer. Increased awareness of this difference may lead to improved medical management on rehabilitation units.

Policy issues related to the rehabilitation of the surgical cancer patient.

Four policy challenges that face the rehabilitation community in providing services to surgical cancer patients are reviewed: (1) achieving capacity to meet the complex rehabilitation needs of a growing population of cancer patients and long-term survivors; (2) identifying effective models for delivering cancer rehabilitation services; (3) understanding complex insurance coverage and payment policies and determining their effects on access to rehabilitation services; and (4) investing in clinical and health services research to guide rehabilitation practice. Recommendations are made to increase the recognition of cancer rehabilitation as an essential component of cancer survivors' care, improve access to appropriate rehabilitation services, and accelerate the pace of cancer rehabilitation research.

Responding to employment concerns of cancer survivors.

The report on cancer survivorship recently released by the Institute of Medicine called on providers to become familiar with the employment rights of survivors, to offer them information about employment rights and programs, and to help minimize the adverse effects of cancer on employment. This review is designed to help providers respond to the Institute of Medicine's recommendations by describing relevant employment and health insurance protections, nationally accessible services and information sources for survivors, functional limitations that may affect survivors' work, and a variety of rehabilitation services that may be helpful for survivors with disabling residual effects of cancer and its treatment. It also suggests directions for further efforts on the part of public and private cancer organizations, researchers, and clinicians to address the employment concerns of survivors.