Response and Intervention to Elevated ESAS Scores: A Chart Audit of Gynecologic Oncology Clinics

Abstract

While the incorporation of patient-reported outcomes (PROs) in oncology has several benefits, data pertaining to symptom management practices are limited. The objective of this study was to evaluate health care professional (HCP) documentation of elevated PRO symptom scores and subsequent intervention. This was a retrospective chart review of gynecologic oncology patients within a single institution. The Edmonton Symptom Assessment System (revised version) (ESAS-r) is a validated, PRO tool that evaluates 9 common symptoms and is completed prior to each clinic visit. Symptom management intervention guidelines exist for each symptom based on severity: mild (1-3), moderate (4-6) and severe (≥7). Biopsy-proven gynecologic oncology patients with any ESAS symptom score ≥4 were eligible. A stratified sampling method was used: 100 patients were randomly selected with 20 per year from 2012 to 2016. Patient, tumor and treatment characteristics were collected. HCP documentation of symptoms with score ≥4 and subsequent interventions were assessed by 2 independent oncologists. Interventions were categorized as: counselling, investigation, treatment or referral. Descriptive statistics were used to report symptom prevalence, HCP documented response and intervention. Fisher’s exact test evaluated documentation and intervention rates according to individual symptom severity and total ESAS score. Between January 2012 and December 2016, a total of 5849 patients completed the ESAS. Symptoms scores were ≥ 4 in 3216 patients (55%) and ≥ 7 in 1446 (25%). In our sample of 100, ovarian malignancies were most common (42%), followed by endometrial (34%). Median age was 55 years (range 47-63). The median total ESAS score was 24 (range: 17-39). The most prevalent symptoms were tiredness (70%), anxiety (61%) and poor appetite (40%). Overall, documentation of a least one symptom ≥ 4 occurred in 50 patients (50%), most commonly for pain (71%) and tiredness (36%) and least commonly for depression (11%) and nausea (4%). An intervention was offered to only 32 patients (32%), most commonly for pain (56%) and least commonly for nausea (4%). The primary intervention was a treatment recommendation (12/32; 38%). Higher median total ESAS score was associated with higher rate of documentation (p=0.002) and higher rate of intervention (p<0.001). Similarly, higher symptom severity was significantly associated with higher rate of documentation, except for anxiety and nausea, and higher rate of intervention, except for anxiety, nausea and tiredness. A significant proportion of gynecologic oncology patients report elevated symptom scores that should prompt an intervention. However, HCPs document symptoms in only half of patients and offer interventions in only one third, warranting further evaluation. A study exploring the barriers and facilitators of optimal ESAS use is underway.