Symptom Assessment Tools Research Articles

Identifying Potential Adverse Effects by Patients’ Ratings

Methods to evaluate adverse effects of medications are significantly underdeveloped compared to those for efficacy. In this pilot proof-of-concept study, we preliminarily compared a novel approach-the Symptom Assessment Tool (SAT)-to a systematic and detailed assessment by a physician for identifying symptoms that were potentially adverse effects (sensitivity) and excluding symptoms that were unlikely to be adverse effects (specificity). A symptom inventory and rating of symptom severity were completed before starting a psychotropic medication (or increasing its dose), and again 2 weeks later. Each symptom was systematically assessed by the patient-rated SAT and by a physician and was classified as either a potential or unlikely adverse effect. The primary analysis compared the classification of symptoms by the SAT to that by the physician. Potential adverse effects were also subcategorized as possible or probable adverse effects. A sample of 193 symptoms from 15 adults was evaluated, only 37.3% of which were considered potential adverse effects by the physician. Sensitivity of the SAT compared to physician's assessment was 90.3% for potential adverse effects and 97.5% for the subgroup of probable adverse effects. The SAT correctly identified 63.6% of the symptoms as unlikely adverse effects (specificity), and its negative predictive value was 91.7%. The SAT, appropriate for its intended use as a screening tool, had high sensitivity and moderate specificity and could present physicians with a limited number of potential adverse effects for further assessment and intervention. Further evaluation and refinement of this approach is warranted.

Impact of a cancer management program.

227 Background: US Oncology, Inc., Texas Oncology (TxO) and Aetna are engaged in a pilot program, Innovent Oncology (IOP) to evaluate clinical and financial impacts of Pathways (PW), a nursing call intervention for chemotherapy patients (pt support services-PSS), and an advance care planning (ACP) initiative. We report quality initiatives, PW compliance and ACP, from the program at 18 months, and IP and ER admits at 12 months. Methods: Eligible Aetna pts with PW diagnoses, treated by TxO were enrolled. PW compliance was tracked. PSS calls occurred at regular intervals during chemotherapy. Symptoms, quality of life, and depression were screened each call with referrals to TxO as needed for management. ACP was initiated in month 2 of IOP. To support IOP, a leadership team comprising physicians, pharmacists and nurses was established. IP,ER data on predefined subgroups were compared to diagnosis-adjusted rates from the baseline prior year. Results: The program enrolled 184 patients from June 1, 2010 – Decembe 30, 2011 with 278 regimens ordered. Pathway adherence improved from 67% to 75%. 81% enrolled in PSS; of these, 83% were introduced to ACP, with 11% (n=16) completing a full ACP discussion. PSS made 906 calls to pts and assessed pain at 80% of contacts. IP, ER utilization rates after 12 months of IOP are reported (see Table). Conclusions: This is a preliminary evaluation with small numbers. Results suggest cancer patients can be identified pre-treatment; a proactive nurse call system is feasible and well received; a symptom assessment tool can be systematically implemented, communication on ACP initiated; and a pathways program enhanced. A reduction of ER visits by 39.8%, IP admits by 16.5 %, and inpatient days/member by 35.9% are very promising trends. A bootstrap shows 97% of scenarios with IP utilization reduction, and 96% with ER utilization reduction. [Table: see text]

Urge Perception Index of Bladder Hypersensitivity

By analyzing bladder diaries with patient self-reported urinary perception grades, we developed the urge perception index, a quantitative measure of bladder hypersensitivity. We evaluated the impact of the urge perception index on the definition of overactive bladder severity. We retrospectively evaluated the records of 69 female patients who visited our outpatient clinic with the complaint of storage symptoms. Patients were asked to complete the overactive bladder symptom score and a 3-day bladder diary with self-reported grading of urinary perception on a range of 1 to 5 per void. Overactive bladder was diagnosed in 43 patients and nonoveractive bladder was diagnosed in 26. The urge perception index was defined as voided volume divided by the urinary perception grade at each void. We analyzed 1,578 reported voids. According to the urinary perception grade, urge perception index values for overactive bladder were significantly lower than those for nonoveractive bladder (grades 1 to 4 p <0.001). The average ± SD urge perception index in 3-day bladder diaries was lower in overactive than in nonoveractive bladder cases (55 ± 28 vs 133 ± 73, p <0.0001). The most severe (lowest) single urge perception index value during the 3 days was significantly lower in patients with overactive than with nonoveractive bladder (mean 20 ± 12 vs 62 ± 40, p <0.0001). There were negative linear correlations of the urge perception index with total overactive bladder symptom scores (r = -0.598, p <0.0001) and with an urgency symptom score (r = -0.557, p <0.0001). The urge perception index, an integrated parameter of patient reported bladder perception and voided volume, could be promising to quantify the severity of overactive bladder or bladder hypersensitivity by bladder diary analysis.

Variation in Health-Related Quality of Life by Line of Therapy of Patients with Chronic Lymphocytic Leukemia

AbstractAbstract 3926 Introduction.Chronic lymphocytic leukemia (CLL) patients will have significant variation in signs and symptoms at initial presentation and across lines of therapy, with concomitant effect on patient health-related quality of life (HRQOL). HRQOL and other patient-reported outcomes, together with clinical outcomes, provide a more complete perspective on the burden of disease and facilitate a broader view of the impact of treatment regimens. This analysis evaluates whether the HRQOL of patients with CLL in the United States (US) varies at the time the patients are about to embark on various lines of therapy, and offers a baseline report from which subsequent longitudinal analysis post-treatment will be possible. Methods.Clinical and HRQOL data were collected in Connect®CLL, a prospective observational registry initiated in March 2010 involving centers in the US. Physicians provided data on the demographics and clinical characteristics of patients receiving therapy. HRQOL was self-reported by patients at enrollment using the Brief Fatigue Inventory (BFI, a symptom assessment tool), the EQ-5D (a non-disease-specific HRQOL instrument), and the Functional Assessment of Cancer Therapy-Leukemia (FACT-Leu, a leukemia-specific HRQOL instrument). We characterized patients who had initial (First Line), second (Second Line) or subsequent (Higher Line) treatment regimens prior to initiation of regimens. Reported mean overall and/or domain-specific BFI, EQ-5D and FACT-Leu scores were analyzed by line of therapy. Statistical significance of score differences among sub-cohorts was ascertained by ANOVA using SAS 9.1. Results.Evaluable data were reported on 1005 patients, enrolled from 161 centers (93% community, 7% academic). Patients were predominantly male (62%) and white (89%) with mean age at 69 (standard deviation [SD] 11) years. HRQOL scores by line of therapy are presented:HRQOL ScoresFirst line (n=633)Second line (n=197)Higher line (n=175)P-valueBFI Mean (SD)Global4.1 (2.4)4.3 (2.4)4.2 (2.4)0.0423*Severity4.9 (2.7)5.1 (2.8)4.9 (2.5)0.0181*Interference3.7 (2.5)3.9 (2.5)3.9 (2.6)0.1007EQ-5D, mean (SD)Index overall0.87 (0.14)0.84 (0.15)0.83 (0.15)0.0195*VAS overall73.8 (19.6)70.7 (19.9)69.8 (18.5)0.0232*Mobility domain1.2 (0.4)1.3 (0.5)1.3 (0.5)0.0091*Self Care domain1.0 (0.2)1.1 (0.3)1.1 (0.2)0.1453Usual Activities domain1.4 (0.5)1.5 (0.6)1.4 (0.6)0.1280Pain/Discomfort domain1.4 (0.5)1.5 (0.6)1.5 (0.5)0.0049*Anxiety/Depression domain1.3 (0.5)1.3 (0.5)1.4 (0.5)0.7132FACT-LEU Mean(SD)Physical22.9 (4.4)22.2 (4.9)22.0 (5.3)0.0129*Social/Family23.8 (4.8)23.6 (5.1)22.6 (5.8)0.0819Emotional19.2 (3.7)19.5 (3.6)18.7 (3.9)0.1820Functional19.9 (5.9)19.5 (6.0)19.1 (6.6)0.4145Leukemia subscale50.2 (9.6)48.9 (10.9)47.3 (11.1)0.0023*FACT-G Total85.8 (13.9)84.6 (14.1)82.5 (15.9)0.0372*FACT-LEU Total136.3 (21.7)133.4 (22.7)129.8 (25.1)0.0039*P-value from ANOVA among three groups.*Statistically significant at 0.05.The total FACT-Leu and FACT-G results, and the total EQ-5D Index and Visual Analogue Scale (VAS) results, consistently suggest that patients initiating first line therapy have somewhat better HRQOL compared with those initiating subsequent lines of therapy. FACT-Leu total scores of patients initiating first line therapy were associated with better physical and leukemia-specific considerations, and the EQ-5D total score was associated with better mobility and pain/discomfort. Conclusions.Initial results from the Connect® CLL Registry indicate that HRQOL prior to treatment is better among patients initiating first line therapy compared to patients initiating later lines of treatment. Future analyses should be conducted to determine what clinical or other factors may be associated with the HRQOL deterioration in patients initiating subsequent lines of therapy, so as to inform clinician decision making. Also, subsequent longitudinal analyses should be undertaken to determine how HRQOL might be affected by the different lines of therapy and the specific treatment regimens, as well as by their initial HRQOL and other patient factors. Disclosures:Kay:Celgene: Research Funding. Flowers:Celgene: Consultancy; Prescription Solutions: Consultancy; Seattle Genetics: Consultancy; Millennium: Research Funding, Unpaid consultancy, Unpaid consultancy Other; Genentech: Unpaid consultancy, Unpaid consultancy Other; Gilead: Research Funding; Spectrum: Research Funding; Janssen lymphoma research foundation: Membership on an entity's Board of Directors or advisory committees. Weiss:Celgene: Consultancy. Lamanna:Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding. Flinn:Celgene: Research Funding. Grinblatt:Celgene: Honoraria, Speakers Bureau. Kipps:Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding. Kozloff:Celgene: Consultancy. Lerner:Celgene Connect: Membership on an entity's Board of Directors or advisory committees. Sharman:Celgene: Consultancy; Pharmacyclics: Honoraria; Calistoga: Honoraria; Portola pharmaceuticals: Consultancy. Khan:Celgene Corporation: Employment, Equity Ownership. Street:Celgene: Employment, Equity Ownership. Swern:Celgene: Employment. Sullivan:Celgene: Employment. Pashos:Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding.

Clinical Usefulness of the Two-Question Assessment Tool for Depressive Symptoms in Japanese Patients with Chronic Obstructive Pulmonary Disease

Depressive symptoms are highly prevalent in patients with chronic obstructive pulmonary disease (COPD) and have been associated with poor outcomes. Developing a concise questionnaire to measure depressive symptoms in COPD patients is needed in outpatient settings. We evaluated the clinical usefulness of a concise two-question instrument to assess depressive symptoms in patients with COPD. The study was conducted as a cross-sectional analysis in patients with COPD. All patients completed a self-reported questionnaire consisting of the two-question instrument, as well as a shortened version of the Center for Epidemiologic Studies Depression Scale (CESD-10) to measure depressive symptoms. Performance of the two-question instrument was evaluated using the results for CESD-10 as standard. We also measured patients' health-related quality of life using the Medical Outcomes Study 8-Item Short-Form Health Survey (SF-8) to determine whether the instrument was related to SF-8. Sensitivity of the two-question instrument in the detection of depressive symptoms was 73.3 % (95 % confidence interval [CI] 51-95.7), specificity was 73 % (95 % CI 58.7-87.3), and area under the receiver operating characteristics curve was 0.73 (95 % CI 0.59-0.87). When study patients were divided into two groups with a cutoff of 1 point on the two-question instrument, scores for all subscales of the SF-8 except "bodily pain" were significantly lower in patients with than without depressive symptoms. This concise two-question instrument is useful as assessment of depressive symptom in patients with COPD in busy outpatient settings.

Using Myeloproliferative Neoplasm Symptom Assessment Form (MPN-SAF) to Evaluate Quality of Life for MPN Patients in Qatar

AbstractAbstract 5069 Background:Myeloproliferative neoplasms (MPNs), that is, essential thrombocythemia (ET), polycythemia vera (PV), and myelofibrosis (MF), are a group of MPNs that can lead to significant rates of morbidity and mortality among affected patients. Specifically, patients in the early stages of these illnesses (ET, PV, and early MF) can be predisposed to thrombohemorrhagic events and vascular complications. Long-term complications of MPNs (either primary MF or MF arising from an antecedent ET or PV) can include progressive cytopenias, constitutional symptoms, cachexia and weight loss, moderate to massive splenomegaly, and risk of blastic transformation.Symptomatic burden in myeloproliferative neoplasms (MPNs) is present in most of MPN patients We sought to use broadly applicable instrument (MPN-SAF) to assess symptoms in myelofibrosis (MF), essential thrombocythemia (ET) and polycythemia vera (PV) among populations of Qatar. Methods:Using the MF-SAF as a base instrument, we added several key additional symptoms previously identified as present in all subtypes of MPNs including headaches, concentration, dizziness, extremity tingling, insomnia, sexual problems and mood changes on a 0 (absent) to 10 (worst-imaginable) scale. The MPN-SAF was administered jointly with the EORTC-QLQ-C30 as the co-validation instrument using prospective cohorts in Qatar (Patients referred to National Centre for Cancer Care and Research).Results: MPN-SAF Patient data:123 MPN-SAF surveys were administered (English (45%), Arabic (55%) in 45 ET patients (36. 5 %%), 35 PV patients (28. 5%), and 15 MF patients (12. 2%), 28 MPN unclassified (22. 7%) an average of 7. 8 years (range 0 – 43 years) from their MPN diagnosis. Participants were of, age range (26 – 58 years) and gender (52% female) characteristic of disease. Prior hemorrhage (10%) and thrombosis (25%) were frequent. 78% of patients currently received cytoreductive therapy and 87% received cytoreductive therapy in the past. Patients and Symptomatic Burden:19 items assessed in the MPN-SAF demonstrated consistently that the most common symptoms were decreased quality of life (93%), fatigue (84%), insomnia (65%), sad mood (65%), and sexuality problems (62%). The least common symptoms (<50% prevalence) were fevers (15%), weight loss (10%), abdominal pain (23%), cough (34%), headache (50%), and bone pain (48%). Symptoms were most severe in MF, followed by ET, then PV patients. Although symptoms are present in all 3 MPN subgroups, itching is notably more burdensome in PV patients (65%, median score of 2. 8 out of 10). Interestingly, night sweats (present in 58%). The majority found the MPN-SAF easy to understand (92%) and “addressed most of my MPN symptoms” (95%). Comparison to EORTC-QLQ-C30:Strong correlations existed between individual items represented on both the MPN-SAF and the EORTC-QLQC30 including pain, fatigue, appetite and insomnia (all p<0. 001). Additionally key symptomatic elements were highly correlated with the EORTC QLQ-C30 functional subscales. Comparison to Physician Perceptions:Comparison of the results of the MPN-SAF to enrolling physicians’ blinded opinion of patients symptoms (8 assessed - night sweats, fevers, fatigue, weight loss, bone pain, and pruritus) showed excellent correlation with corresponding patients’ responses (all p<0. 001). Serial MPN-SAF Results:Pearson correlations indicate that most MPN-SAF items are well correlated (r >0. 5, p<. 001) upon repeat survey administration. Items characteristic of advanced disease, including weight loss, fever, and cough displayed lower Pearson correlations (r=0. 46, −0. 08, and 0. 38 respectively). Conclusions:The MPN-SAF is comprehensive and reliable instrument which is available in multiple languages (including Arabic and English) to evaluate MPN-associated symptoms. The MPN-SAF is recommended as a uniform symptom assessment tool for MPN patient. Disclosures:Yassin:Qatar National Research Fund: Patents & Royalties, Research Funding. Off Label Use: use of pegelated interferon alfa 2a in treatment of patients with ET. Rafii El-Ayoubi:Qatar National Research Fund: Patents & Royalties, Research Funding. Al-Dewik:Qatar National Research Fund: Patents & Royalties, Research Funding.

Assessment of patient-reported measures of bowel function before and after pelvic radiotherapy: an ancillary study of the North Central Cancer Treatment Group study N00CA

The Bowel Function Questionnaire (BFQ) has been used in clinical trials to assess symptoms during and after pelvic radiotherapy (RT). This study evaluated the importance of symptoms in the BFQ from a patient perspective. Patients reported presence or absence of symptoms and rated importance of symptoms at baseline, 4 weeks after completion of pelvic RT, and 12 and 24 months after RT. The BFQ measured overall quality of life (QOL) and symptoms of nocturnal bowel movements, incontinence, clustering, need for protective clothing, inability to differentiate stool from gas, liquid bowel movements, urgency, cramping, and bleeding. Bowel movement frequency also was recorded. A content validity questionnaire (CVQ) was used to rate symptoms as "not very important," "moderately unimportant," "neutral," "moderately important," or "very important." Most of the 125 participating patients rated all symptoms as moderately or very important. Generally, patients gave similar ratings for symptom importance at all study points, and ratings were independent of whether the patient experienced the symptom. Measures of greatest importance (moderately or very important) at baseline were ability to control bowel movements (94 %), not having to wear protective clothing (90 %), and not having rectal bleeding (94 %). With the exception of need for protective clothing, the presence of a symptom at 4 weeks was associated with significantly worse QOL (P < .01 for all). The BFQ has excellent content validity. Patients rated most symptoms as moderately or very important, indicating the BFQ is an appropriate tool for symptom assessment during and after pelvic RT.

Evaluation of Factors Influencing the Natural History of Nocturia in Elderly Subjects: Results of the Fujiwara-kyo Study

We evaluated the natural history of nocturia and determined factors influencing the incidence or remission of nocturia. Study subjects were 4,427 volunteers 65 years old or older who participated in the Fujiwara-kyo Study. The nocturia prevalence was assessed at baseline and 1 year later. Nocturia incidence and remission rates were calculated and factors influencing these results were evaluated based on characteristics, including gender, age, body mass index, HbA1c, creatinine clearance, life style, comorbidities, depressive status, metabolic syndrome and voiding symptoms. Independent factors were determined by multivariate analysis. Of the 4,427 subjects 3,685 provided complete replies to self-administered questionnaires at baseline and 1 year later. The prevalence of nocturia at baseline and 1 year later was 47.0% and 50.3%, and nocturia incidence and remission rates were 20.0% and 15.4%, respectively. Male gender, high body mass index, voiding symptom deterioration and new onset overactive bladder were independent factors associated with the nocturia incidence. Male gender, sum of the voiding symptoms, age and new onset overactive bladder were independent negative factors associated with nocturia remission. The prevalence of nocturia worsened with time, although nocturia in older subjects progressed dynamically. Male gender, age, body mass index, sum of voiding symptoms, voiding symptom deterioration and new onset overactive bladder influence the natural history of nocturia.

403 - Quality of Life and Symptoms in Breast Cancer Patients Undergoing Conventional Chemotherapy

ABSTRACT Disclosure All authors have declared no conflicts of interest. Quality of life (QoL) and symptom assessment are of increasing importance to evaluate treatment outcomes in breast cancer patients. We aimed to study feasibility of using standardized QoL and symptom assessment tools to determine benefits and risks of conventional chemotherapy (CT) in breast cancer patients. One hundred and seven breast cancer patients (Stages I-IV) were included in the study (58% patients with metastatic breast cancer). Mean age/SD – 53/10 y.o. All the patients underwent taxane based CT with the previous treatment including CT (89%), surgery (69%), radiotherapy (39%), hormone therapy (24%) or biotherapy (9%). QoL was assessed using generic QoL questionnaires, the SF-36 and the EQ-5D; symptoms – by using Comprehensive Symptom Profile in Patients with Breast Cancer (CSP-Br). The CSP-Br is a self-reported tool which allows to assess the severity of 57 symptoms specific for breast cancer patients. Distribution of patients according to the grades of QoL impairment was analyzed using the SF-36. For comparison of means at different time-points Wilcoxon's matched pairs test was used. The patients reported the usefulness of PROs tools to facilitate patient-physician communication. The following distribution of patients receiving taxane based CT according to the grades of QoL impairment was observed: 23% of patients had no QoL impairment; 15% patients - mild QoL impairment, 33% - moderate or severe QoL impairment, and 19% - critical QoL impairment. Health index measured by the EQ-5D decreased during the CT cycle and improved by the next CT cycle. The most prevalent and disturbing symptoms were the following: hair loss (>90%), fatigue, feeling of constant tiredness (>80%) and psychological symptoms (>70%). Definite deterioration of symptom profile and severity was observed in a week after CT cycle completion: the severity of 21 out of 47 symptoms increased significantly (p

Patient assessment of measures of bowel function during and after pelvic radiation therapy: An ancillary study of North Central Cancer Treatment Group study N00CA.

e16572 Background: The Bowel Function Questionnaire (BFQ) has been used in clinical trials to document patient-reported symptoms following pelvic radiation therapy (RT). This study evaluated the importance patients placed on the symptoms included in the BFQ as measured by a Content Validity Questionnaire (CVQ). Methods: Patients treated with pelvic RT assessed symptoms and importance at baseline, after completion of RT (4 weeks), and 12 and 24 months. BFQ measured quality of life (QOL) and symptoms of: nocturnal bowel movements, incontinence, greater than one bowel movement in 30 minutes, need for protective clothing, inability to differentiate stool and gas, liquid bowel movements, urgency, cramping, and bleeding. Bowel movement frequency was also assessed. Symptoms were rated via the CVQ as “not very important,” “moderately unimportant,” “neutral,” “moderately important,” or “very important." Summary statistics were compiled. Fisher Exact, Chi-Square and Wilcoxon methodology compared BFQ and CVQ results. Results: 125 patients participated. All symptoms were rated as moderately important or very important by most patients.Measures of bowel function of greatest importance (moderately or very important) at baseline were ability to control bowel movements (94%), not having to wear protective clothing (90%), and not having rectal bleeding (93%). In general, patients gave similar ratings of symptom importance at all time points in the study and ratings were independent of whether the symptom was experienced. With the exception of the need for protective clothing, the presence of a symptom at 4 weeks was associated with significantly worse QOL (p-values &lt; 0.001 to 0.005). Conclusions: The BFQ has excellent content validity. Patients rated most symptoms measured by the BFQ as moderately important or very important, indicating the BFQ is an appropriate tool for symptom assessment during and after pelvic RT. With the exception of the need for protective clothing, the presence of every symptom measured by the BFQ was associated with worse QOL. These criteria make them appropriate targets for future research to mitigate radiation-related bowel dysfunction.

Validation of the Head and Neck Patient Symptom Checklist as a nutrition impact symptom assessment tool for head and neck cancer patients

The purpose of this study was to test the validity of the Head and Neck Patient Symptom Checklist (HNSC). Three hundred and sixty-eight treatment-naive individuals with head and neck cancer prospectively completed the HNSC and the Patient-Generated Symptom Global Assessment (PG-SGA). The predictive validity was determined by comparing the HNSC symptoms interference scores to the PG-SGA scores. Multivariate logistic regression was used to determine the HNSC symptoms scores associated with reduced dietary intake, ≥ 5 % weight loss over 6 months, and reduced functional performance (FP). HNSC sensitivity (79-98 %), specificity (99-100 %), positive predictive value (92-100 %), and negative predictive value (94-100 %) were excellent, and the Cronbach's alpha coefficient was 0.92. The multivariate logistic regression showed that advanced tumor stage, pain, loss of appetite (LOA), and difficulty swallowing significantly predicted dietary intake. Advanced tumor stage, LOA, and difficulty swallowing were also significant predictors of ≥ 5 % weight loss over 6 months. LOA, difficulty swallowing, feeling full, and lack of energy were significant predictors of reduced FP. The HNSC appears to be a valid tool for determining symptoms interfering with dietary intake of head and neck cancer (HNC) patients. This instrument may aid in early identification of symptoms that place HNC patients at risk for reductions in dietary intake, weight, and functional performance.

Previous Chemotherapy Influences the Symptom Experience and Quality of Life of Women With Breast Cancer Prior to Radiation Therapy

Recent evidence suggests that women who receive treatment for breast cancer may experience multiple symptoms that decrease their functional status and quality of life. Few studies evaluated the occurrence, severity, and distress of multiple symptoms in women at the initiation of radiation therapy (RT) for breast cancer. This study evaluated for differences in symptoms occurrence, severity, and distress between women with breast cancer who did and did not receive chemotherapy (CTX) prior to RT. Prior to the initiation of RT, patients completed the Memorial Symptom Assessment Scale (MSAS) that evaluated multiple dimensions of 32 symptoms. Differences in occurrence, severity, and distress scores between the 2 CTX groups were evaluated using χ and Mann-Whitney U tests. The 5 symptoms with the highest occurrence rates were lack of energy, worrying, difficulty sleeping, feeling drowsy, sweats, and pain. Women who received CTX prior to RT experienced twice as many symptoms as women who did not receive CTX. Except from difficulty sleeping, the 5 most prevalent symptoms were not the most severe or distressing. A poorer functional status, a higher comorbidity score, and previous CTX were all predictors of a higher number of symptoms. Women with breast cancer experience large numbers of symptoms at the initiation of RT. Previous CTX doubles the number of symptoms that women report. Findings suggest that clinicians need to use a multidimensional symptom assessment tool in women with breast cancer at the initiation of RT.

Comparing the use of Edmonton symptom assessment system (ESAS-r) in hospice & oncology outpatients

Current guidance, nationally and internationally, would suggest within oncology and hospice outpatient settings holistic assessment be completed. However how this should occur and what assessment tool be used, there is...

Gastrointestinal Symptom Representation in Cancer Symptom Clusters: A Synthesis of the Literature

To review how gastrointestinal (GI)symptoms are represented within symptom clusters in patients with cancer receiving chemotherapy. MedLINE, PsycINFO, and CINAHL. Forty-two symptom clusters containing a GI component emerged. Only four clusters were replicated in different samples; 38 were unique clusters. Thirteen different symptom measurement tools were used across the studies. Nineteen different GI symptoms were measured; however, many chemotherapy- or cancer-related GI symptoms known to be present in this population were missing or underrepresented. Twenty-one of the studies reviewed identified a symptom cluster that was primarily (50% or greater) composed of GI symptoms. GI symptoms are prevalent in symptom clusters, but those clusters often are inconsistent. One explanation for this finding may be that current symptom measurement tools do not fully address GI symptoms commonly experienced by patients receiving chemotherapy. Future research should focus on using a comprehensive symptom assessment tool in a homogenous sample of participants who are receiving chemotherapy. Improved measurement of GI symptoms will advance symptom cluster research, which could impact assessment of chemotherapy-related symptoms and development of interventions for symptom clusters.

Association between Patient-Reported Symptoms and Nurses' Clinical Impressions in Cancer Patients Admitted to an Acute Palliative Care Unit

Clinicians typically rely on their own or the nurses' clinical impression (NI) of symptoms rather than patient self-reports. It is unclear whether these means of assessment yield similar results. To prospectively compare patient-reported symptoms on a modified Edmonton Symptom Assessment System (ESAS) with NI scores. Consecutive patients with advanced cancer admitted to our acute palliative care unit between April and July 2010 were studied. We collected the results of the ESAS on the day of admission (D1) to the unit and 2 days later (D3). We also collected the NI of each patient's physical and psychological distress on D1 and D3. One hundred eighteen patients completed the ESAS on D1 and 116 on D3. On D1 there was no significant association between NI score and ESAS assessment except for dyspnea, which was weakly correlated with NI score for physical distress (r=0.22, p=0.02). The median ESAS physical and psychosocial scores were 31 and 12 in patients with NI of low or no physical distress, versus 34 (p=0.07) and 15 (p=0.18) in patients with NI of moderate or severe distress, respectively. On D3, we found a significant association between ESAS and NI only for pain (r=0.32, p<0.001) and anxiety (r=0.30, p=0.001). Sensitivity and specificity of the NIs for ESAS scores were low on both days. The clinical impression of highly trained palliative care nurses showed poor association with patient-reported symptom intensity. Validated symptom assessment tools are needed for bedside clinical assessment.

Exploring the Challenges of Implementing the Edmonton Symptom Assessment Scale in a Specialist Palliative Care Unit

Background: Many symptom assessment tools have been developed to aid evaluation of patient’s symptoms. The Edmonton Symptom Assessment Scale is one such tool. The ESAS was introduced on the inpatient unit in Milford Hospice (a 30 bedded tertiary palliative care unit) in December 2007. However, a 3-month chart review revealed a low completion rate (20%) of the ESAS. Aim: The aim of this study was to assess the reasons for the low completion rate of the ESAS in the unit. Methods: A mixed methods approach using both questionnaire and focus group was undertaken. The population sampled was the nursing staff who were responsible for ensuring the completion of the ESAS in the unit on a daily basis. Results: The main reason for the low completion rate of the ESAS was that nursing staff perceived that it was too burdensome for sick patients to complete (76%). Also, nursing staff felt that the tool was not clinically helpful and that it was too time consuming for patients to regularly complete. Other important issues relating to the introduction process for symptom assessment tools are also identified. Conclusions: The results of this study are consistent with findings in the literature relating to other symptom assessment tools. Implementing such tools may be burdensome for patients with a poor functional status in an advanced cancer setting. Areas of focus for further research include shorter symptom assessment tools which are more reflective of a patients twenty four hour symptom profile, and also proxy rated assessment tools.

Remote doctoring is only part of online health

In England, the use of everyday technologies to provide easier access to urgent care and to improve health began at scale in the late 1990s with the telephone. Over the past 12 years, remote health advice and information have become an established part of the NHS scene. 2010 was the first year in which more people contacted NHS Direct over the Internet than by telephone. That trend is expected to continue as smartphones become ubiquitous, as more tools become available for people to self-serve online, and as we continue to learn how and where these approaches add most value for patients and the NHS. Reports that Professor Sir Bruce Keogh is drawing up plans to introduce online consultations1 are very welcome. But experience clearly shows that, in health as in other sectors, the transformative effect of the web does not lie primarily in opening up new channels for traditional interactions. Its greatest power is to enable safe, high quality self-service, underpinned by the best available medical expertise, to support patients themselves to manage their health and make better informed decisions about their care. It is commonplace now to look at retail banking as an indicator of how technology can drive new business models, improving customer experience and reducing cost by harnessing people's willingness to do things for themselves. In retail banking, the creation of digital services has enabled rationalization of the physical estate, something the NHS badly needs. Between 2000 and 2010, the number of UK customers registered for telephone banking increased from 16 m to 46 m but began to fall from their peak in 2006. Over the same period, online bank accounts multiplied from 1.4 m to 40 m and continued to rise beyond 2010, approaching the telephone as the leading remote channel. Meanwhile the number of high street branches fell from over 12,000 to under 10,000.2 The revolution in banking has not come about through replacing visits to the branch with remote access to clerks and managers by telephone or web, but through technology-enabled self-service. The debate about remote consultations now starting in the NHS is reminiscent of the banking sector in the 1990s. Over several years, the senior leaders in a major retail and business bank developed a blueprint for the banking of the future. They envisaged technology instantly bringing a range of data feeds to lending officers’ desktops, including economic forecasts, both local and national; business sector performance; and personal credit history – essentially using digital resources to augment the traditional model of thousands of lending decisions by individual experts. The technology to support this vision turned out to be relatively expensive and slow in coming. Meanwhile, in the back offices, a real revolution was taking place as analysts, statisticians and programmers developed the software that automated decision-making and provided self-service credit decisions for millions of customers, rendering the original blueprint obsolete before it ever materialized. The NHS's early attempts at remote self-service have shown themselves to be safe and popular with patients. In 2009, the National Pandemic Flu Service (NPFS) carried out 2.7 million remote assessments, enabling 1.8 million people to access prescription-only antiviral medication without seeing or even speaking to a qualified health professional.3 Forty percent of these assessments were self-service over the web. The safety and effectiveness of the NPFS did not depend on individual judgements by the hundreds of staff around the country who were rapidly recruited and trained in response to the pandemic, but on the medical expertise embedded within the assessment algorithm. Day by day and week by week, as researchers learned more about the virus, the algorithm was updated in real time, giving every patient the benefit of the most up-to-date medical knowledge, wherever they happened to be. Similarly, the power of NHS Direct's suite of 40+ digital symptom assessment tools lies in the quality of the medical expertise which underpins them, coupled with growing experience in how to apply consumer digital techniques to present health information and support decision-making online. The symptom checkers have now been used over 12 million times,4 and the mobile apps launched in May 2011 have been used over a million times. Continuous careful monitoring of adverse incidents gives no reason to believe that these digital tools threaten patient safety. We are just beginning to see the benefits of people taking the technologies they use every day, and applying them to manage their health. The rapid adoption that we have seen of digital health tools by consumers, will increasingly enable high cost face-to-face and physical resources to be devoted to the people and situations that need them. The greatest potential is the use of technology to support patient self-management so, while supporting remote doctoring, we need to take care that it does not become a distraction from the real prize.

Patient or Physician - Who Is Able to Evaluate Gastroesophageal Reflux Disease Symptoms Better?

Patient or Physician - Who Is Able to Evaluate Gastroesophageal Reflux Disease Symptoms Better?

PECC—Factor structure and findings in three longitudinal cohorts of patients with schizophrenia

Background: Symptom control by drug treatment is the most important task in routine clinical care of patients with schizophrenia. Structured assessment methods are needed in this task but not used much. The US-developed Positive and Negative Syndrome Scale (PANSS) is a standard tool for symptom assessment. The Psychosis Evaluation tool for Common use by Caregivers (PECC) was constructed in Europe some years ago, with the intent to overcome some of the PANSS drawbacks. Aims and methods: To validate PECC on three longitudinal cohorts of schizophrenic patients representative of Swedish outpatients (n = 225, six assessments over 5 years), international forensic patients (n = 186) and matched non-forensic controls (n = 116), five assessments over 2 years for both. Results: The factor structure of PECC appears to be highly robust. Norm values (in percentiles) were calculated on the materials. Such data provides for analyses of symptom profiles and improvement over time measured in absolute numbers. Forensic patients appear to have a much lower symptom load (except for cognitive symptoms) than the other groups. Forensic controls had much shorter inpatient times than any other group and never caught up with respect to symptom control, even after 2 years. These differences suggest that the scale is clinically valid. Conclusion: PECC has a more robust factor structure than PANSS and is simpler to use. Percentile norms have been constructed for outpatients with schizophrenia in general and forensic psychiatry. Percentile scores are accessed readily by the net. PECC is available in many languages. Its separate self-harm item may improve assessments of suicide risk among patients with schizophrenia.

Symptom improvement as prognostic factor for survival in cancer patients undergoing palliative care: a pilot study

The Edmonton Symptom Assessment Scale (ESAS) is a validated tool for physical symptom assessment in palliative care practice which evaluates symptoms through a numeric scale from 0 to 10. The use of symptom improvement as a prognostic factor is controversial. To this purpose, a pilot study in advanced cancer patients now undergoing only palliative care was conducted. Patients were considered eligible if no longer able to receive any anticancer treatment; they were scheduled to undergo ESAS assessment at the hospitalization and hospital discharge time points. Symptoms' scores were divided into three severity classes: mild, moderate and severe. Differences across symptoms' classes between hospitalization and hospital discharge time points were analysed with the paired-data McNemar test, according to tumour types. ESAS assessment was administered to 68 patients with gastrointestinal (39 patients) and non-small cell lung cancer (29 patients); median age was 69 years; Karnofsky Performance Status was 50 in 27 (39.7%) patients and >50 in 41 (60.3%) patients. Palliative Prognostic Score was A for 26 (38.2%) patients, B for 37 (54.4%) patients and C for 5 (7.4%) patients. A statistically significant reduction of severe severity class rates was observed. Symptom improvement correlates with survival improvement: Palliative Prognostic Score (hazard ratio (HR) 2.95, 95% CI 1.35-6.41, p = 0.006) and anorexia (HR 3.21, 95% 1.33-7.72, p = 0.009) appear to be prognostic factors for survival at the multivariate analysis for gastrointestinal cancer patients; asthenia is the only significant variable (HR 5.11, 95% CI 1.86-14.03, p = 0.002) for non-small cell lung cancer patients. Symptom improvement according to ESAS after palliative care treatment represents an important prognostic for survival in patients no longer suitable to receive any anticancer active therapies.