Symptom Management Guidelines Research Articles

Symptom Management Guideline Implementation Among Nurses in Cancer-Specific Outpatient Settings: A Scoping Review of Barriers, Facilitators, and Implementation Strategies.

Oncology outpatients experience high levels of distressing cancer-related symptoms. Nurses can provide high-quality outpatient cancer symptom management following clinical practice guideline recommendations; however, these guidelines are inconsistently used in practice. Understanding contextual factors influencing implementation is necessary to develop tailored implementation strategies. To identify and describe (1) barriers and facilitators influencing symptom management guideline adoption, implementation, and/or sustainability among nurses in cancer-specific outpatient settings and (2) components of strategies used to enhance guideline implementation. A scoping review was conducted following Joanna Briggs Institute methodology. CINAHL, EMBASE, EMCARE, MEDLINE, and gray literature sources were searched. Eligibility screening and data extraction were performed in duplicate. The updated Consolidated Framework for Implementation Research and Expert Recommendations for Implementing Change taxonomy informed data extraction and descriptive analysis. Thirty-six projects from 2004 to 2023 were included; most used quality improvement (n = 14) or quasi-experimental (n = 10) designs. Determinants were most often mapped to the "inner setting" and "individuals-roles/characteristics" Consolidated Framework for Implementation Research domains. Most projects used multiple discrete implementation strategies within the "train and educate stakeholders" (n = 29, 85%) and/or "develop stakeholder interrelationships" (n = 20, 59%) categories. Nurses may face several barriers to symptom management guideline implementation within cancer-specific outpatient setting workflows and may have limited opportunity to implement guidelines within their current roles. Most projects used educational strategies, which alone may be insufficient to address reported barriers. By identifying barriers, facilitators, and strategies, this scoping review can be used to design tailored strategies to implement symptom management guidelines within outpatient oncology nursing care.

A pragmatic approach to selecting a grading system for clinical practice recommendations in palliative care

Background: The limited palliative care evidence base is poorly amenable to existing grading schemes utilized in guidelines. Many recommendations are based on expert consensus or clinical practice standards, which are often considered ‘low-quality’ evidence. Reinforcing provider hesitancy in translating recommendations to practice has implications for patient care. Aim: To rationalize the selection of an appropriate grading system for rating evidence to support recommendations made in palliative care clinical practice guidelines. Design: Review of the methodology sections of international palliative care guidelines published in English identified five grading systems comparison: Grading of Recommendations, Assessment, Development and Evaluations (GRADE); the Scottish Intercollegiate Guidelines Network (SIGN); Infectious Diseases Society of America-European Society for Medical Oncology (IDSA-ESMO); Confidence in the Evidence from Reviews of Qualitative research (CERQual) and the National Service Framework for Long Term Conditions (NSF-LTC). Results: There is heterogeneity among grading systems used in published palliative care or terminal symptom management guidelines. GRADE has been increasingly adopted for its methodological rigour and inter-guideline consistency with other medical associations. CERQual has the potential to support recommendations informed by qualitative evidence, but its role in clinical guidelines is less defined. The IDSA-ESMO system has an intuitive typology with the ability to categorize tiers of lower-quality evidence. Conclusions: It is challenging to apply commonly used grading systems to the palliative care evidence base, which often lacks robust randomized controlled trials (RCTs). Adoption of IDSA-ESMO offers a feasible and practical alternative for lower-resourced guideline developers and palliative clinicians without a prerequisite for methodological expertise.

Treatment Patterns for Plantar Fibromatosis in the United States: A Retrospective Observational Study

Category: Midfoot/Forefoot; Other Introduction/Purpose: Plantar fibromatosis (PF) is a rare disease affecting the plantar aponeurosis, characterized by disordered fibrous tissue and subsequent formation of subcutaneous nodules on the foot/feet. There are no established clinical guidelines for management of PF symptoms, and real-world evidence on treatment patterns among PF patients in the United States (US) is scarce. This retrospective observational study used a comprehensive approach to identify newly diagnosed PF patients and describe subsequent conservative (non-surgical) and surgical treatment patterns. Methods: Patients with evidence of PF from ICD-9/10 diagnosis codes in IQVIA’s PharMetrics® Plus were identified between January 2015-March 2020 and linked to IQVIA’s Ambulatory Electronic Medical Records (AEMR) to confirm diagnosis, using PF- specific SNOMED diagnosis codes or problem name; the earliest evidence of PF was the diagnosis date. Further, eligible patients were required to have continuous enrollment (CE) in a health plan for 12 months before diagnosis (baseline), 24 months of CE after diagnosis (follow-up), evidence of PF ≥30 days after first diagnosis, and age ≥18 years on diagnosis date. Patients with prior diagnosis of PF (through 2014) or other select lower limb conditions during baseline were excluded. Baseline demographic/clinical characteristics and conservative treatment utilization prior to PF diagnosis were assessed. Proportion of patients receiving PF- related conservative and surgical treatment, frequency of use, and time from diagnosis to initiation of first treatment were reported during follow-up. Results: The incident PF cohort (N=620) had mean (SD) age of 52.2(9.9) years and 63.2% were women. Most common baseline comorbidities were thyroid diseases (14.2%), diabetes without complications (12.3%), and smoking (12.3%); 19.0% had evidence of foot or ankle pain/stiffness. During baseline, 53.5% of patients received prescribed analgesic medications (30.6% received opioids). Most patients (91.1%) received conservative treatment after PF diagnosis, including analgesics and physical/occupational therapy (Figure 1A). Among all treatment modalities, time to initiation (months) was shortest for orthotics (median:0.5; IQR:5.5), injectable corticosteroids (median:2.0; IQR:9.2) and prescribed NSAID (median:2.5; IQR:9.1; Figure 1B). Among 42 patients (6.8%) receiving PF-related surgery, conservative treatments were common both before surgery (83.3%; median time from diagnosis to surgery:6.0 months) and after surgery (92.9%). Conclusion: Most newly diagnosed PF patients received conservative treatments within the first 3 months after diagnosis. Analgesic use was high during baseline as well as follow-up. During the 24 months after diagnosis, few patients received surgery and conservative treatment modalities often continued after surgery. Overall, continued and widespread conservative management among PF patients indicates lack of treatment options for PF. Further studies on treatment patterns in US patients aged ≥65 years are needed.

Clinician perspectives on barriers and solutions to symptom management in cystic fibrosis

People living with cystic fibrosis (PLwCF) experience high symptom burden. 146 clinicians completed online surveys regarding barriers and solutions to symptom management between September and October 2020. The surveys contained both closed-ended and free-text entries. The symptom management specialists that CF clinicians most wished to consult included mental health (88, 65%), palliative care (59, 41%), and pain specialists (48, 33%). Barriers to symptom management included concerns about controlled substances prescribed for symptom control causing addiction and precluding transplantation, a lack of trust and collaboration among clinical specialties, a lack of symptom management specialists with CF expertise, and a worry about the affordability of specialist-level symptom management care. Potential solutions included non-pharmacological approaches, expanding access to affordable specialist symptom management care, the creation of clinical care guidelines for symptom management in CF, and having CF clinicians and symptom management specialists work alongside each other in CF clinic to build interdisciplinary trust and education.

Evaluation and Management of Postsurgical Patient With Hirschsprung Disease Neurogastroenterology & Motility Committee: Position Paper of North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN).

Children with Hirschsprung disease have postoperative long-term sequelae in defecation that contribute to morbidity and mortality and significantly impact their quality of life. Pediatric patients experience ongoing long-term defecation concerns, which can include fecal incontinence (FI) and postoperative obstructive symptoms, such as constipation and Hirschsprung-associated enterocolitis. The American Pediatric Surgical Association has developed guidelines for management of these postoperative obstructive symptoms and FI. However, the evaluation and management of patients with postoperative defecation problems varies among different pediatric gastroenterology centers. This position paper from the Neurogastroenterology & Motility Committee of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition reviews the current evidence and provides suggestions for the evaluation and management of postoperative patients with Hirschsprung disease who present with persistent defecation problems.

Implementation strategies to address barriers to evidence-informed symptom management among outpatient oncology nurses: a scoping review protocol

IntroductionDespite the availability of clinical practice guidelines for cancer symptom management, cancer care providers do not consistently use them in practice. Oncology nurses in outpatient settings are well positioned to...

A Person-Centered Approach to Symptom Assessment and Management for Children and Adolescents Receiving Cancer Treatment.

Discuss the clinical assessment and management of symptoms for children and adolescents receiving treatment for cancer with attention to a person-centered approach to care. Review of currently published literature and guidelines pertaining to symptom assessment and management for children and adolescents receiving treatment for cancer. Symptoms such as pain, nausea, and fatigue are commonly reported by children and adolescents receiving cancer treatment and are associated with greater symptom burden. Symptom assessment should be tailored to the child or adolescent and include the child's or adolescent's preference for reporting symptoms and attention to the symptoms that are of greatest priority. Evidence-based guidelines for the management of symptoms, including pain and nausea, are available to guide symptom management interventions and should be tailored to provide person-centered care. Nurses can lead efforts through clinical practice and research initiatives to advance person-centered symptom care for children and adolescents with cancer on a global level. Priorities for future work to advance person-centered symptom assessment and management include (1) identification of best practices for symptom assessment, (2) attention to social determinants of health and their subsequent influence on symptom outcomes, (3) compilation of evidence for management of less commonly reported symptoms, and (4) implementation of published clinical guidelines for symptom management in practice settings.

The self-perceived palliative care barriers and educational needs of clinicians working in hospital primary care teams and referral patterns: lessons learned from a single-center survey and cohort study.

Within the generalist-plus-specialist palliative care model, palliative care is mainly provided by nurses and physicians of hospital primary care teams. Palliative care consultation teams (PCCTs) support these clinicians in adequately caring for patients with advanced illnesses. Our team started in 2012. The aim of this study was to assess the self-perceived barriers, educational needs and awareness of available palliative care support options among our hospital primary care teams. In addition, palliative care referral patterns were evaluated. Single-center mixed methods study. Outcomes of two surveys of primary care team clinicians (2012 and 2016) on barriers to palliative care, educational needs and awareness of palliative care support options were compared (chi-square, Mann-Whitney U tests, qualitative analysis). Palliative care referral characteristics were evaluated (2012-2017), including referral timing (survival since referral) (descriptive statistics, Kaplan-Meier methodology). Predictions of survival at referral were analyzed (weighted Kappa). In 2012 and 2016, the most frequently reported barrier was the late initiation of the palliative care approach. Clinicians reported a need for education on physical symptom management and basic palliative care principles. Awareness of support options increased from 2012 to 2016, including improved familiarity with the PCCT (56% vs. 85%, P<0.001) and positive appraisal of the team (8% vs. 40% gave an 'excellent' rating, P<0.001). The use of national symptom management guidelines also improved (23% vs. 53%, P<0.001). Of 1,404 referrals, 86% were for cancer patients. Referrals increased by 28% (mean) per year. Medical oncology clinicians referred most frequently (27%) and increasingly early in the disease trajectory (survival ≥3 months after referral) (P=0.016). Median survival after referral was 0.9 (range, 0-83.3) months. Referring physicians overestimated survival in 44% of patients (kappa 0.36, 95% CI: 0.30-0.42). Primary care team clinicians persistently reported needing support with basic palliative care skills. PCCTs should continuously focus on educating primary care teams and promoting the use of guidelines. Because physicians tend to overestimate survival and usually referred patients late for specialist palliative care, consultation teams should support primary care teams to identify, treat and refer patients with palliative care needs in a timely manner.

Guidelines for Management of Urgent Symptoms in Patients with Cholangiocarcinoma and Biliary Stents or Catheters using the Modified RAND/UCLA Delphi Process.

Background: Patients with cholangiocarcinoma often have indwelling biliary stents or catheters which are prone to obstructions and/or infections; studies show that 20–40% present with fever and/or jaundice requiring urgent treatment in the outpatient setting for which there are no uniform guidelines. The goal was to develop an expert panel consensus on this topic using the modified RAND/UCLA Delphi process to rate treatment appropriateness. Methods: Thirteen expert physicians from relevant specialties, geography, and practice settings were recruited for the panel. Patient scenarios were developed and panelists rated the therapies before and after a face-to-face discussion. The appropriateness of various therapies was rated on a scale from 1–9 and classified as appropriate, inappropriate, or uncertain. Scenarios with greater than 2 (>2) ratings of 1–3 (inappropriate) and greater than 2 (>2) ratings of 7–9 (appropriate) were considered to have disagreement and were not assigned an appropriateness rating. Results: Panelists were from all US regions and the UK (8%) and had practiced for a mean 16.5 years (4–33 years). Panelists rated 480 scenarios before the meeting and re-rated 288 of the clinical scenarios after the meeting. The panelists agreed that ongoing treatment with chemotherapy did not influence decision-making and, therefore, 192 scenarios were excluded from the final list. Disagreement decreased from 37.5% before to 10.4% after the meeting. Consensus on stent/tube manipulation and inpatient antibiotic therapy was obtained and summarized in patients as “appropriate” or “maybe appropriate” based on a patient’s bilirubin level at presentation. Conclusions: The Delphi process produced consensus guidelines to fill an unmet need in the urgent management of ascending cholangitis in patients with cholangiocarcinoma.

Symptom Experiences in Colorectal Cancer Survivors After Cancer Treatments: A Systematic Review and Meta-analysis.

With improved survivorship rates for colorectal cancer (CRC), more CRC survivors are living with long-term disease and treatment side effects. Little research exists on CRC symptoms or symptom management guidelines to support these individuals after cancer treatments. The aims of this study were to systematically review symptom experiences, risk factors, and the impact of symptoms and to examine the pooled frequency and severity of symptoms via meta-analyses in CRC survivors after cancer treatments. Relevant studies were systematically searched in 7 databases from 2009 to 2019. Meta-analysis was conducted for pooled estimates of symptom frequency and severity. Thirty-five studies met the inclusion criteria. Six studies assessed multiple CRC symptoms, whereas 29 focused on a single symptom, including peripheral neuropathy, psychological distress, fatigue, body image distress, cognitive impairment, and insomnia. The pooled mean frequency was highest for body image distress (78.5%). On a scale of 0 to 100, the pooled mean severity was highest for fatigue (50.1). Gastrointestinal and psychological symptoms, peripheral neuropathy, and insomnia were also major problems in CRC survivors. Multiple factors contributed to adverse symptoms, such as younger age, female gender, and lack of family/social support. Symptoms negatively impacted quality of life, social and sexual functioning, financial status, and caregivers' physical and mental conditions. Colorectal cancer survivors experienced multiple adverse symptoms related to distinct risk factors. These symptoms negatively impacted patients and caregivers' well-being. Healthcare providers can use study findings to better assess and monitor patient symptoms after cancer treatments. More research is needed on CRC-specific symptoms and their effective management.

Chapter 31 - Pediatric traumatic brain injury and abusive head trauma

Childhood traumatic brain injury (TBI) commonly occurs during brain development and can have direct, immediately observable neurologic, cognitive, and behavioral consequences. However, it can also disrupt subsequent brain development, and long-term outcomes are a combination of preinjury development and abilities, consequences of brain injury, as well as delayed impaired development of skills that were immature at the time of injury. There is a growing number of studies on mild TBI/sport-related concussions, describing initial symptoms and their evolution over time and providing guidelines for effective management of symptoms and return to activity/school/sports. Mild TBI usually does not lead to long-term cognitive or academic consequences, despite reports of behavioral/psychologic issues postinjury. Regarding moderate to severe TBI, injury to the brain is more severe, with evidence of a number of detrimental consequences in various domains. Patients can display neurologic impairments (e.g., motor deficits, signs of cerebellar disorder, posttraumatic epilepsy), medical problems (e.g., endocrine pituitary deficits, sleep-wake abnormalities), or sensory deficits (e.g., visual, olfactory deficits). The most commonly reported deficits are in the cognitive-behavioral field, which tend to be significantly disabling in the long-term, impacting the development of autonomy, socialization and academic achievement, participation, quality of life, and later, independence and ability to enter the workforce (e.g., intellectual deficits, slow processing speed, attention, memory, executive functions deficits, impulsivity, intolerance to frustration). A number of factors influence outcomes following pediatric TBI, including preinjury stage of development and abilities, brain injury severity, age at injury (with younger age at injury most often associated with worse outcomes), and a number of family/environment factors (e.g., parental education and occupation, family functioning, parenting style, warmth and responsiveness, access to rehabilitation and care). Interventions should identify and target these specific factors, given their major role in postinjury outcomes. Abusive head trauma (AHT) occurs in very young children (most often <6 months) and is a form of severe TBI, usually associated with delay before appropriate care is sought. Outcomes are systematically worse following AHT than following accidental TBI, even when controlling for age at injury and injury severity. Children with moderate to severe TBI and AHT usually require specific, coordinated, multidisciplinary, and long-term rehabilitation interventions and school adaptations, until transition to adult services. Interventions should be patient- and family-centered, focusing on specific goals, comprising education about TBI, and promoting optimal parenting, communication, and collaborative problem-solving.

Feasibility of a randomized controlled trial of symptom screening and feedback to healthcare providers compared with standard of care using the SPARK platform

Supportive care Prioritization, Assessment and Recommendations for Kids (SPARK) is a web-based application that enables symptom screening and access to clinical practice guidelines for symptom management. Objective was to determine the feasibility of a randomized trial of daily symptom screening for 5days among children receiving cancer treatments. We included English-speaking pediatric cancer and hematopoietic stem cell transplantation (HSCT) patients who were 8-18years of age at enrollment and who were expected to be in the hospital or in clinic daily for five consecutive days. We randomized children to either undergo daily symptom screening with symptom reports provided to the healthcare team using the SPARK vs. standard of care. The primary endpoint was feasibility, defined as being able to enroll at least 30 participants within 1year, and among those randomized to intervention, at least 75% completing symptom screening on at least 60% of on-study days. From July 2018 to November 2018, we enrolled and randomized 30 participants. The median age at enrollment was 12.5 (range 8-18) years. Among the intervention group, the median number of days Symptom Screening in Pediatrics Tool (SSPedi) was completed at least once was 5 (range 4 to 5), with one participant missing 1day of symptom screening. Among all participants, baseline and day 5 SSPedi scores were obtained in 29/30 participants. A randomized trial of the SPARK with daily symptom screening for 5days was feasible. It is now appropriate to proceed toward a definitive multi-center trial to test the efficacy of SPARK to improve symptom control.

Longitudinal evaluation of Supportive care Prioritization, Assessment and Recommendations for Kids (SPARK), a symptom screening and management application

BackgroundSupportive care Prioritization, Assessment and Recommendations for Kids (SPARK) is a web application focused on improving symptom control. It enables pediatric cancer and hematopoietic stem cell transplant (HSCT) patients to self-report and track symptoms, and allows healthcare professionals to access guidelines for symptom management. Objective was to determine the feasibility of longitudinal collection of symptom data.MethodsIn this longitudinal, single-armed feasibility study, respondents were children 8–18 years of age with cancer or pediatric HSCT recipients. Participants completed symptom reporting daily for 5 days. Cognitive interviews were conducted on day 5. Quantitative evaluation included SPARK ease of use and understandability of SPARK reports. Qualitative feedback on facilitators and barriers to daily symptom screening was solicited. Feasibility was defined as ≥75% of participants completing symptom screening on at least 60% of on-study days during the five-day study.ResultsAmong the 30 children enrolled, the median number of days SSPedi was completed at least once was 5 (range 3 to 5). Overall, 28/29 (96.6%) thought completing symptom screening using SPARK was easy or very easy. All participants understood SPARK symptom reports. Severe symptoms was the most common barrier to daily reporting while an alarm reminder system was the most commonly identified facilitator.ConclusionsDaily completion of symptom screening using SPARK over 5 days was feasible in children aged 8 to 18 years with cancer and pediatric HSCT recipients. SPARK is now appropriate for use in randomized trials to evaluate the effect of symptom screening and symptom feedback.

Mental health in elite athletes: International Olympic Committee consensus statement (2019)

Mental health symptoms and disorders are common among elite athletes, may have sport related manifestations within this population and impair performance. Mental health cannot be separated from physical health, as...

Clinical Guidelines for Management of Gastrointestinal Symptoms in Cancer Patients: The Japanese Society of Palliative Medicine Recommendations.

Background: Gastrointestinal symptoms, including nausea, vomiting, bowel obstruction, ascites, constipation, and anorexia, are common and often refractory in advanced cancer patients. The palliation of gastrointestinal symptoms is important in improving the quality of life of cancer patients, as well as that of their families and caregivers. Currently published clinical guidelines for the management of gastrointestinal symptoms in cancer patients do not comprehensively cover the topics or are not based on a formal process for the development of clinical guidelines. Methods: The Japanese Society for Palliative Medicine (JSPM) developed comprehensive clinical guidelines for the management of gastrointestinal symptoms in cancer patients after a formal guideline development process. Results: This article summarizes the recommendations along with their rationale and a short summary of the development process of the JSPM gastrointestinal symptom management guidelines. We established 31 recommendations, all of which are based on the best available evidence and agreement of expert taskforce members. Discussion: Future clinical studies and continuous guideline updates are required to improve gastrointestinal symptom management in cancer patients.

A systematic review of symptom experiences in survivors of colorectal cancer.

186 Background: Colorectal cancer (CRC) is the third most common cancer diagnosis in the US. With expanding survival rates, increasing numbers of CRC survivors live with long-term disease and treatment-side effects. There is limited research about symptom experiences from which to provide evidence-based symptom management guidelines for CRC survivors. This study systematically reviews published studies on symptoms in CRC survivors, with an aim to understand symptom experiences and with a broad goal of developing effective symptom interventions and improving CRC survivorship. Methods: A systematic search for relevant studies between the years 2005-2018 was conducted with Scopus, CINAHL, Medline via PubMed, Web of Science, EMBASE, Cochrane Library (CENTRAL), and PsycINFO. A systematic literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Results: Of an initial 588 unique studies, 33 were identified for inclusion in the systematic review. The majority of studies were conducted in the UK or had a cross-sectional design. The European Organization for Research and Treatment of Cancer Quality of Life-C30 was the most frequently used instrument to assess symptoms. When we converted symptom severity scores and symptom occurrences among CRC survivors on a 0-100 scale, the most severe and frequently reported symptom across the 33 studies was fecal incontinence (mean severity: 50 points; mean occurrence: 52%), followed by fatigue (mean severity: 49 points; mean occurrence: 44%). Patients who reported lack of symptom management information, poor family and social supports, and presence of a stoma also reported more frequent and more severe symptoms. Symptom experiences were correlated with poor quality of life, low physical activity, daily life interferences, problems with sexual relationships, financial concerns, and negative body image. Conclusions: CRC survivors experienced a unique set of symptoms. Research is needed on symptom trajectories across the cancer continuum, strategies to incorporate family and other social supports for managing symptoms, and to enhance communication between oncologists, patients and caregivers that will support improved symptom control.

Treatment Recommendations for Urological Symptoms in Cancer Patients: Clinical Guidelines from the Japanese Society for Palliative Medicine

Urological symptoms such as gross hematuria, lower and upper urinary tract symptoms, and bladder pain are common in and distressing for patients with advanced cancer. Although palliation of urological symptoms is important to improve the quality of life of cancer patients and their families and caregivers, clinical guidelines for managing urological symptoms in patients with cancer have not been published. Following the formal guideline development process, the Japanese Society for Palliative Medicine (JSPM) developed comprehensive clinical guidelines for the management of urological symptoms in patients with cancer. This article summarizes the recommendations and their rationales and provides a short summary of the development process of the JSPM urological symptom management guidelines. We established five recommendations, all of which were based on the best available evidence and expert consensus. JSPM released the first edition of the "Clinical Guidelines for Urological Symptoms in Cancer Patients." Future clinical research and continuous guideline updates are required to improve the quality of managing urological symptoms in patients with cancer.

1517P - Current status of the integration of oncology and palliative care in Japan: A nationwide survey

Background: Based on recommendations from several agencies, including the European Society for Medical Oncology, palliative care (PC) services are increasingly recognised as an essential part of oncology care. However, the implementation of integration of oncology and palliative care (IOP) seems to be evolving slowly and detailed progress of IOP remain unclear. This was a cross-sectional nationwide survey to clarify the current status of IOP in Japan. Methods: We performed comparison between designated cancer hospitals (DCHs) and non-designated cancer hospitals (non-DCHs), since considerable number of patients in Japan are receiving cancer treatment at non-DCHs. We distributed the questionnaire to executives or directors of oncology departments at cancer hospitals in November 2017 and sent a reminder mail later. Our questionnaire was developed based on indicators of IOP with international consensus. We conducted descriptive statistics, t-tests and Cochrane-Armitage trend tests where appropriate. To adjust the difference of inpatient beds scale, estimates at non-DCHs were weighted by the distribution of inpatient beds at DCHs. Results: Among the 399 DCHs and 478 non-DCHs that were surveyed, 269 (67%) and 259 (54%) responded, respectively. DCHs had significantly more PC resources than non-DCHs did (e.g. both full-time physicians and nurses on a PC team, 53% vs. 14% (p < 0.001); the availability of outpatient PC service ≥ 3days per week, 48% vs. 21% (p < 0.001)). Clinical tools for PC services were well equipped (e.g. symptom management guidelines, 89% vs. 79% (p = 0.238); PC referral criteria, 72% vs. 59% (p = 0.077)). However, strategies to identify suitable patients for PC referral seemed to be undeveloped (e.g. clinical care pathways, 17% vs. 5% (p < 0.001); referral using time trigger, 9% vs 8% (p = 0.358); referral using needs trigger, 31% vs. 20% (p = 0.820)). Mutual rotation training for both oncology and PC fellows and research opportunities on IOP were limited. Conclusions: Non-DCHs face a severe lack of PC resources, whereas DCHs might have relatively more resources to enhance IOP. Both education and research opportunities for IOP were limited. Further research is warranted to identify specific barriers to and facilitators for implementation of IOP. Legal entity responsible for the study: Graduate School of Medicine, Kyoto University. Funding: Ministry of Health Labor and Welfare in Japan (Health Labor Science Research Grant). Disclosure: All authors have declared no conflicts of interest.

The implementation and evaluation of HIV symptom management guidelines: A preliminary study in China

ObjectiveThe overarching objective of this study was to examine the effectiveness of HIV symptom management guidelines in China in reducing the incidence and severity of symptoms and improving patients' quality of life. MethodsWe conducted a controlled, pre- and post-implementation design in the HIV/AIDS inpatient unit in Shanghai. Patients recruited from November 2014 to February 2015 were in the intervention group and those from October 2013 to February 2014 were in the control group. There were 74 patients in each group. Participants in the intervention group received interventions based on the HIV symptom management guidelines. Overall symptom severity, depression, and quality of life were measured in two groups at baseline, week 4, and week 8. ResultsTotally 126 patients completed the research, 65 in the intervention group and 61 in the control group. The total symptom severity scores showed a statistically significant difference between groups across time (P < 0.05). It showed that frequencies of fatigue (36.9% vs. 44.3%), fever (6.2% vs. 11.5%), loss in weight (9.2% vs. 16.4%), mouth ulcers (12.3% vs. 16.4%), headaches (9.2% vs. 19.7%) and depression (F = 1.09, P > 0.05) in the intervention group were lower than those in the control group in week 8 without statistical significance. The multilevel growth mixture model indicated a greater increase in the total score of quality of life for the group treated according to the symptom management guidelines (P = 0.04). ConclusionThe evidence-based HIV symptom management guidelines can improve a patient's quality of life and relieve negative symptoms. The guidelines can be applied in a similar context to other HIV/AIDS units or clinics.

Guidelines for management of urgent symptoms in cholangiocarcinoma (CC) patients (pts) with biliary stents or catheters using the modified RAND/UCLA Delphi process.

e15641 Background: CC pts with biliary stents or catheters are prone to have obstruction/infection and studies show 20-40% present with fever/or jaundice requiring urgent treatment for which there is no uniform guideline. We aimed to develop an expert panel consensus on this topic using the modified RAND/UCLA Delphi process to rate treatment appropriateness. Methods: We recruited 13 physician experts from relevant specialty, geography, and practice settings. Patient scenarios were developed and panelists rated the therapies before and after a face-to-face discussion. The appropriateness of various therapies was rated on a 1-9 scale and classified as appropriate, inappropriate, or uncertain. Scenarios with &gt; 2 ratings of 1-3 (inappropriate) and &gt; 2 ratings of 7-9 (appropriate) were considered to have disagreement and were not assigned an appropriateness rating. Results: Panelists were from all US regions (92%) and the UK (8%); had practiced for a mean 16.5 years (4-33 years). Panelists rated 480 scenarios before the meeting, but re-rated only 288 clinical scenarios as they felt that ongoing treatment with chemotherapy did not influence decision-making. Disagreement decreased from 37.5% before the meeting to 10.4% after. Consensus statements are summarized in the table below. Conclusions: The Delphi process produced consensus guidelines to fill an unmet need in urgent management of ascending cholangitis in pts with CC. (Support: The Cholangiocarcinoma Foundation). [Table: see text]