Nurse practitioner-led lung cancer screening clinic: An evidence-based quality improvement evaluation.

BACKGROUND: Lung cancer is the leading cause of cancer deaths worldwide. Screening for lung cancer using low-dose computed tomography of the chest (LDCT) can reduce mortality associated with lung cancer. LDCT is an under-ordered screening study. AIMS: To evaluate the use of a nurse practitioner-led lung cancer screening clinic (LCSC). METHODS: The absolute number of LDCT for lung cancer screenings obtained 12 months before implementing the nurse practitioner-led LCSC was compared to the 12 months after clinic implementation using a casual comparison design. An electronic survey was conducted to assess the LCSC key stakeholders' perceptions of the clinic. RESULTS: An increase of 60% in the total number of LDCT for lung cancer screenings was observed. Qualitative data obtained through stakeholder evaluation of the clinic revealed that 85% of participants (n = 13) expressed that the LCSC was addressing barriers to lung cancer screening. LINKING EVIDENCE TO ACTION: A dedicated nurse practitioner-led LCSC is a practical way to increase lung cancer screening by addressing established barriers to screening in the community setting.

Evaluating Readability Scores of Treatment Summaries and Cancer Survivorship Care Plans.

PURPOSE: Treatment Summaries and Survivorship Care Plans (TS/SCPs) may be difficult for patients to comprehend because of readability, magnitude of information, and complex medical verbiage. METHODS: Readability scores were calculated for TS/SCP templates including ASCO, Oncolink, Journey Forward, and the authors' institution. The Simple Measure of Gobbledygook (SMOG) index, Flesch-Kincaid reading grade level, Coleman-Liau Index, and Gunning Fog index were used to assess readability. RESULTS: The Flesch-Kincaid reading ease scores for the blank ASCO templates ranged from 47.4 to 53.3, requiring a reading grade level of 10-12. Coleman-Liau and Gunning Fog scores showed that an 11th grade reading level is essential, and SMOG required a college education to comprehend the ASCO templates. For the colorectal case exemplar, Oncolink's template resulted in the lowest SMOG score (11.3; 11th grade), Flesch-Kincaid reading grade level (11; 11th grade), and Coleman-Liau score (12; 12th grade). Journey Forward's TS/SCP template scored the highest on the SMOG (21.2; college graduate), Flesch-Kincaid reading grade level (18.3; college graduate), and Gunning-Fog index (25.8; college graduate) compared with other TS/SCPs. CONCLUSION: The existing TS/SCP templates used by US cancer centers are written at a grade level beyond the comprehension of most adults. Cancer care teams should assess TS/SCP content for readability and use of plain language and reduce medical jargon.

Implementation of a Smoking Cessation e-Learning Education Program for Oncology Clinic Healthcare Providers: Evaluation With Implications for Evidence-Based Practice.

BACKGROUND: Continued smoking after a cancer diagnosis increases the risk for treatment complications, primary cancer recurrence, and secondary malignancy development, while also reducing treatment efficacy, survival, and overall health. The lack of formal evidence-based smoking cessation education programs for oncology healthcare providers is a barrier to smoking cessation practices. PURPOSE: To evaluate the use of an evidence-based, smoking cessation e-learning education program for oncology healthcare providers. METHODS: A single group, pre- and post-test, nonexperimental design was used in this evidence-based quality improvement project. To assess the provider's knowledge in smoking cessation, a baseline assessment, a post-test, and an online survey were completed by the providers. A telephone survey was conducted to assess the patients' perception of cessation services received. RESULTS: The healthcare providers' (N = 58) test scores on smoking cessation knowledge increased significantly (p < .0001) after completing the e-learning education program. A majority of the providers reported that the education program increased their confidence (86%) in successfully helping the patient to quit smoking and agreed to make smoking cessation a priority (89%) in their practice. A majority of the patients (85%) were satisfied or extremely satisfied with the smoking cessation services received. Many patients (71%) self-reported having tried to quit smoking. CONCLUSION: An evidence-based e-learning education program is effective in increasing oncology healthcare providers' knowledge and confidence in tobacco dependence treatment practices. The program also has a positive impact on oncology patients' perception of cessation services received. LINKING EVIDENCE TO ACTION: A self-paced e-learning program is a feasible and effective way to educate healthcare providers in smoking cessation treatment. Incorporating evidence-based tobacco dependence treatment into their daily oncology practice is warranted.

Decreasing Opioid Use in Pediatric Lower Extremity Trauma: A Quality Improvement Project.

INTRODUCTION: Perioperative anxiety increases postoperative pain and the risk of complications in hospitalized children. Nonpharmacologic pain resources provided by Certified Child Life Specialists (CCLS) are a viable adjunct for pain management. METHOD: A routine CCLS consult was implemented for patients admitted to the orthopedic service with traumatic lower extremity injuries requiring surgery. A retrospective chart review compared patients who did not receive a CCLS consult. Daily pain rating scores, total doses of opioid and nonopioid pain medication, number of physical therapy attempts, length of stay, and demographics were compared for both groups. RESULTS: A clinically significant improvement was seen for decreased pain rating scores and opioid use after a routine CCLS consult was implemented. DISCUSSION: Adopting a routine CCLS consult for children with unplanned admissions because of trauma reduces the number of opioids used, provides children with pain management resources, and promotes coping skills that may be used in the future.

Survivorship Fellowship: Evaluation and Evolution of a Program for Advanced Practice Providers.

A comprehensive cancer center in the midwestern United States implemented a stakeholder-engaged quality improvement process to extend its existing one-year advanced practice provider (APP) fellowship program consisting of general oncology education and clinical experience to include an additional survivorship clinical rotation. APP fellowship alumni and program stakeholders reported noticeable benefits and greater importance attributed to program participation, validating inclusion of a survivorship clinic rotation as part of the fellowship program.

Utilization of an audit tool to evaluate accuracy of treatment summary and survivorship care plans.

PURPOSE: A quality review process was implemented to determine compliance with the requirement from the Commission on Cancer to use the American Society of Clinical Oncology (ASCO) template as the minimum data set for Treatment Summary and Survivorship Care Plans (TS/SCP) provided to cancer survivors. METHODS: TS/SCPs generated during 2017 (N = 1257) were audited for concordance with each of the 66 TS/SCP line items on ASCO's template. Descriptive statistics and chi-square statistics were used to examine line item concordance, overall and by services groups (survivorship vs. other oncology service). Mixed-effects logistic regression was used to estimate the effects of service delivery group on the concordance. RESULTS: Institutional compliance with the ASCO template was very high; 76% of the 66 line items were present in at least 75% of the delivered TS/SCPs. There was a significantly higher rate of concordance for TS/SCPs provided by the survivorship service (83% vs. 66%, P = 0.006). TS/SCPs provided by the survivorship service were nearly twice as likely to be concordant with ASCO template (OR = 1.88, 95% CI = 1.77-2.00) compared to those by other service groups. CONCLUSIONS: Use of the electronic medical record to auto-populate information was instrumental in achieving a high rate of concordance. Institutions should consider providing training to improve or maintain quality of these documents. IMPLICATIONS FOR CANCER SURVIVORS: Ensuring that the information contained on the TS/SCP is consistently present is necessary for a high-quality survivorship visit between the clinician, PCP, and survivor and as a record of care for future health care encounters.

Feasibility of Mind-Body Movement Programs for Cancer Survivors

PURPOSE/OBJECTIVES: To evaluate mind-body movement exercise (MBME) classes (yoga, tai chi, and Qigong) for cancer survivors. 
. DESIGN: A single-group, repeated-measures design.
. SETTING: The Ohio State University Wexner Medical Center-Arthur G. James Cancer Hospital in Columbus.
. SAMPLE: 33 adult cancer survivors, with any cancer diagnosis, participating in MBME classes.
. METHODS: The researchers sought to examine feasibility of multiple data collection time points and data collection measures; acceptability; and changes to physical, emotional, and biometric measures over time, as a result of participation in MBME classes.
. MAIN RESEARCH VARIABLES: Quality of life, sleep, depressive symptomatology, fatigue, stress, upper body strength, gait and balance, body mass index, heart rate, and blood pressure.
. FINDINGS: The current study was feasible because survivors were willing to participate and completed most of the questionnaires. Participants found these classes to be beneficial not only for exercise, but also for social support and social connectedness. Poor sleep quality was consistently reported by participants. MBME classes should be recommended to survivors and are beneficial for oncology practices to offer.
. CONCLUSIONS: Conducting MBME research with cancer survivors is feasible, and participants find the MBME acceptable and a way of addressing health and managing cancer-related symptoms.
. IMPLICATIONS FOR NURSING: Nurses should help patients and caregivers identify locations and times when MBME class participation is possible, assess MBME class participation during each clinic visit to promote continued involvement and to understand if positive effects are occurring, and continue to provide support for MBME classes throughout the survivorship experience.

Adherence to Tobacco Dependence Treatment Among HIV-Infected Smokers.

High prevalence of tobacco use and low success in quitting remain significant problems for reducing disease burden among HIV-infected persons. This study's purpose was to examine participant responsiveness and tobacco dependence treatment adherence and their influences on tobacco abstinence among HIV-infected patients. This non-randomized study included HIV-infected smokers 18 years of age or older, who smoked at least 5 cigarettes per day, and had an interest in quitting smoking in the next 30 days. HIV-infected smokers (n = 247) received a 12-week tobacco dependence treatment intervention that included pharmacotherapy and telephone counseling. Younger age and non-White race were associated with lower adherence to pharmacotherapy. Younger age, non-White race, and increased monthly binge drinking were associated with lower adherence to telephone counseling. High participant responsiveness was associated with adherence to pharmacotherapy, counseling, and abstinence. Development and testing of interventions to improve adherence to evidence-based tobacco dependence treatment is warranted.

Survivorship care plan preferences of cancer survivors and health care providers: a systematic review and quality appraisal of the evidence.

PURPOSE: The purpose of this systematic review was to describe and examine the current use of treatment summaries and survivorship care plans (TSs/SCPs) for cancer survivors, as well as to summarize and critically assess relevant literature regarding their preferences and usefulness. There is a knowledge gap regarding the preferences of stakeholders as to what is useful on a treatment summary or survivorship care plan. METHODS: A systematic review of eligible manuscripts was conducted using preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Relevant studies were identified via PubMed, CINAHL Plus, and the Cochrane Library from 2005 through 2013. Eligible studies were critically appraised with qualitative and quantitative appraisal tools. RESULTS: There were 29 studies included in this review; 19 were quantitative. Survivors and primary care physicians preferred a printable format delivered 0 to 6 months posttreatment and highlighting signs and symptoms of recurrence, late, and long-term effects, and recommendations for healthy living. Oncology providers supported the concept of treatment summary and survivorship care plan but reported significant barriers to their provision. No studies incorporated caregiver perspectives of treatment summary and survivorship care plan. CONCLUSION: This systematic review did not reveal conclusive evidence regarding the needs of survivors or providers regarding treatment summaries and survivorship care plans. A lack of rigorous studies contributed to this. IMPLICATIONS FOR CANCER SURVIVORS: Treatment summaries and survivorship care plans are useful for cancer survivors; however, future rigorous studies should be conducted to identify and prioritize the preferences of survivors regarding these.

Smoking, chronic wound healing, and implications for evidence-based practice.

Chronic wounds are rising in prevalence and creating significant socioeconomic burdens for patients and healthcare systems worldwide. Therefore, it is now more important than ever that clinicians follow evidence-based guidelines for wound care when developing personalized treatment plans for their patients with chronic wounds. Evidence-based guidelines for treating venous leg ulcers, diabetic foot ulcers, and pressure ulcers, the 3 main categories of chronic wounds, focus primarily on biologic therapies. However, there are also evidence-based guidelines for treating behavioral risks to poor healing, such as smoking, which should be incorporated into treatment plans when appropriate. The purpose of this article was to review the mechanisms through which smoking adversely impacts the wound healing process, and propose strategies for incorporating evidence-based guidelines for treating tobacco dependence into treatment plans for patients with chronic wounds who smoke.

Tobacco use and cessation in HIV-infected individuals.

Smoking prevalence estimates among HIV-infected individuals range from 40% to 84%, much higher than the overall US adult prevalence. To date, few tobacco dependence treatment trials have been conducted among HIV-infected smokers. Recommendations for future research include examining underlying factors that contribute to persistent smoking and barriers to abstinence, identifying ways to increase motivation for quit attempts, increasing the number of multicentered 2-arm tobacco dependence treatment trials, and using highly efficacious first-line pharmacotherapy in tobacco dependence treatment intervention studies. Addressing these research gaps will help to reduce the tobacco-related disease burden of HIV-infected individuals in the future.

Safety of varenicline among smokers enrolled in the lung HIV study.

INTRODUCTION: The prevalence of smoking is high among the human immunodeficiency virus (HIV)-infected population, yet there are few studies of tobacco dependence treatment in this population. This paper reports the safety of varenicline versus nicotine replacement therapy (NRT) and describes preliminary results about the effectiveness of varenicline versus NRT in HIV-infected smokers. METHODS: Participants completed 12 weeks of telephone counseling and either varenicline or NRT. Varenicline was encouraged as the preferred intervention; NRT was used for those unable/unwilling to take varenicline. Adverse events (AEs), related to pharmacotherapy, were monitored. Biochemically confirmed abstinence at 3 months was examined. Inverse probability of treatment weighted logistic regression models was fit to compare participants on varenicline to those on NRT. RESULTS: Among participants on varenicline (n = 118), the most common AEs were nausea, sleep problems, and mood disturbances. One person reported suicidal ideation; there were no cardiovascular complications. There were no differences in the varenicline AE profile between participants on combination antiretroviral therapy (ART) and those not on ART. The percentages of confirmed abstainers were 11.8% in the NRT group and 25.6% in the varenicline group. The odds of being abstinent were 2.54 times as great in the varenicline group compared with the NRT group in the propensity weighted model (95% CI 1.43-4.49). CONCLUSIONS: In this preliminary study, the safety profile of varenicline among HIV-infected smokers resembles findings among smokers without HIV. In addition, varenicline may be more effective at promoting abstinence in this population. Future randomized clinical trials are warranted.

A pilot test of a combined tobacco dependence treatment and lung cancer screening program.

Lung cancer screening with computed tomography has demonstrated a significant reduction in mortality. While these findings are important for the lung cancer research field, the most important risk factor for lung cancer, i.e. smoking, should not be ignored. We performed a pilot study to examine the feasibility of delivering a program that included both tobacco dependence treatment and lung cancer screening. The objectives of this study were to: (1) estimate the proportion of smokers who complied with a 12-week treatment protocol that included both tobacco dependence treatment and lung cancer screening, (2) obtain preliminary estimates of abstinence and quit attempts at 4 and 6 months, and (3) obtain preliminary estimates of the cognitive social health information processing (C-SHIP) constructs and how they change following the intervention. In this randomized pilot study, 18 volunteers completed a 12-week protocol: half received the tobacco dependence treatment program before a CT scan (BCT) and the other received the CT scan first, followed by the treatment program (ACT). The treatment protocol included both nurse-delivered telephone counseling and either nicotine replacement therapy or varenicline. Only one person did not complete all follow-up evaluations. At 4 months post enrollment, the carbon monoxide confirmed quit rates were 33.3% in the BCT arm and 22.2% in the ACT arm (27.8% overall), and all but one had made a 24-h attempt to quit. At 6 months the confirmed abstinence decreased to 22.1% in the BCT arm and 11.1% in the ACT arm (16.7% overall), and 72.2% of participants had made a 24-h quit attempt. These preliminary results suggest that it might be better to deliver treatment before the screening test. Future randomized trials with a larger sample size are needed to confirm these findings.

The Self-regulation Model of Illness applied to smoking behavior in lung cancer.

Thirteen to 20% of lung cancer patients continue to smoke after diagnosis. Guided by Self-regulation Theory, the purpose of this study was to examine illness perceptions over time in a sample of lung cancer patients. This prospective 1-group descriptive longitudinal design study included participants 18 years or older, with a lung cancer diagnosis within the past 60 days who self-reported smoking within the past 7 days. At baseline, patients completed a sociodemographics and tobacco use history questionnaire. The Illness Perception Questionnaire-Revised (IPQ-R) was repeated at 3 time points (baseline, 2-4 weeks, and 6 months). Fifty-two participants provided data for the IPQ-R at baseline, 47 at 2 to 4 weeks, and 29 at 6 months. Differences between mean scores for each illness representation attribute of the IPQ-R at repeated time points were calculated by within-subjects repeated-measures analysis of variance and Wilcoxon Signed-Rank Tests. Identity (baseline vs 2-4 weeks: P = .026; baseline vs 6 months: P = .005) and acute/chronic timeline (P = .018) mean scores significantly increased over time; personal and treatment control mean scores significantly decreased over time (P = .007 and P = .047, respectively). Understanding the context in which a patient perceives disease and smoking behavior may contribute to developing interventions that influence behavior change.

A psychometric analysis of quality of life tools in lung cancer patients who smoke.

Lung cancer is the leading cause of cancer death for both men and women in the United States. Patient quality of life (QOL) prior to cancer treatment is known to be a strong predictor of survival and toleration of treatment toxicities. A lung cancer patient's self-assessment of QOL is highly valued among clinicians as it guides treatment-related decisions and impacts clinical outcomes. Smokers are known to report a lower QOL. Limited research has been conducted on QOL outcomes in lung cancer patients who continue to smoke. To assess QOL, a reliable and valid QOL measure specific to lung cancer is required. The functional assessment of cancer therapy-lung cancer (FACT-L) and lung cancer symptom scale (LCSS) are instruments that specifically examine QOL among lung cancer patients. The LCSS is a focused QOL instrument that includes physical and functional domains of QOL and disease symptomatology. The FACT-L is a broader QOL instrument that includes physical, functional, social and emotional domains and disease symptomatology. Both are psychometrically valid and are widely used in the literature, but have not been exclusively evaluated in smokers. Furthermore, there is no 'gold standard' instrument since there has never been a correlation study to compare estimates of reliability and validity between these instruments. The purpose of this study is to report the internal consistency and convergence validity of the FACT-L and the LCSS among newly diagnosed lung cancer patients who smoke. This data were collected and analyzed from a larger study examining smoking behavior among newly diagnosed lung cancer patients (n=51). Descriptive statistics were calculated on the FACT-L and LCSS scores, internal consistency was assessed by estimating Cronbach's alpha coefficients, and Pearson correlation coefficients were estimated between the two scales. Internal consistency coefficients demonstrated good reliability for both scales, and the two instruments demonstrated a strong correlation, suggesting good convergence validity. Either of these instruments are appropriate measures for QOL in lung cancer patients who smoke. Given the conceptual difference between the two instruments, it is important to carefully consider the research aims when selecting the appropriate QOL measurement instrument.

Nursing research in tobacco use and special populations.

Smoking is responsible for approximately one in five deaths in the United States per year. The Surgeon General's 1964 report first linked smoking as a cause of cancer. Since then cigarette smoking has had a steady decline to its current estimate of 19.8%. There are, however, some special populations where smoking continues to occur at a higher prevalence than the general population. This chapter discusses tobacco dependence among the following special populations: low socioeconomic status including Medicaid, hard-core smokers, rural, and homeless; immigrants; and persons living with HIV. For each population, there is an overview of the disparities in tobacco use, special challenges unique to that population, and exploration of current research on tailoring of tobacco dependence treatment. Each of the special populations discussed present unique challenges with tobacco dependence treatment that will require careful examination before disparities will ultimately decrease. Eliminating disparities has been marked as an important research agenda item as noted in Healthy People 2010. Nurse researchers are well positioned to combine their clinical expertise and knowledge of patient psychosocial needs with investigation of patient-focused research questions in each of these special populations.

Socioeconomic disparity in provider-delivered assistance to quit smoking.

The U.S. Public Health Service smoking cessation clinical practice guideline is the accepted gold standard for smoking cessation treatment. It offers evidence-based treatment recommendations for all clinicians to deliver to all patients at each visit. Despite the release of the guideline and the publication of Healthy People 2010, health care providers still may not appropriately counsel patients to quit smoking. Furthermore, disparities may exist among smokers who are assisted to quit smoking by their health care providers. The present study tested for an association between selected sociodemographic and tobacco-related factors and assistance to quit smoking. This 2001 National Health Interview Survey secondary analysis included a U.S. civilian, noninstitutionalized population. Participants were self-reported current smokers who visited a health care provider in the past 12 months and were at least 25 years old. The outcome measure was smokers' self-report of whether assistance to quit smoking was given by a health care provider. Of smokers who received advice (N = 3,046), only 38% received assistance to quit smoking. Smokers were less likely to report assistance to quit smoking if they were younger or Black, or if they had a high or middle level of socioeconomic disadvantage. In the final logistic regression model, being married, attempting to quit in the past 12 months, and consuming more tobacco were associated with receiving assistance to quit smoking. Increased age also was associated with receiving assistance, as was greater socioeconomic advantage (higher education, higher income, health insurance). The mechanisms responsible for the disparities in delivery of tobacco dependence treatment must be investigated further.

Smoking cessation and cancer.

OBJECTIVES: To provide an overview of scientifically based smoking cessation interventions for delivery to all tobacco-dependent users. DATA SOURCES: Research studies, published articles, and government reports. CONCLUSION: Smoking cessation interventions for patients with cancer remain poorly described with only a few studies investigating the efficacy of smoking cessation among this population. However, data suggest that quitting smoking after the diagnosis of cancer improves survival and quality of life. IMPLICATIONS FOR NURSING PRACTICE: Nurses serve a critical role in tobacco-dependence treatment. Innovative interventions for cessation, such as quit lines, telephone counseling, web-based information, and computerized cessation materials are now available.

Factors influencing cotinine half-life during smoking abstinence in African American and Caucasian women.

Cotinine, the proximate metabolite of nicotine, has been identified as an indicator of smoke constituent exposure. Higher cotinine levels in African American cigarette smokers have been identified. Because African Americans experience disproportionate smoking-related morbidity and mortality, it is important to examine potential factors influencing these higher levels of cotinine. The current study examined selected factors of ethnicity, menthol cigarette preference, body composition and alcohol-use history on cotinine half-life in 6 days of smoking abstinence in African American and Caucasian women. A 7-day inpatient protocol was conducted in the General Clinical Research Center, in which day 1 was ad lib smoking and days 2-7 were smoking abstinence (n = 32). Plasma cotinine was measured every 8 h throughout. Average cotinine half-life was 21.3 h, similar to previously reported 18-20 h. Three women exhibited >14 ng/ml cotinine after 136 h of smoking abstinence. Host factors explaining 52.0% of variance in cotinine half-life and associated with longer half-life were being an African American menthol smoker, fewer years of alcohol use and greater lean body mass. Among menthol smokers, baseline cotinine level and cotinine half-life were not significantly different in Caucasian and African American women. Intra-individual cotinine half-life variation and CYP2A6 genotype were examined in substudies. To improve accuracy in correctly classifying non-smokers with cotinine levels, a period of at least 7 days of smoking abstinence may be warranted.