Objective: The systematic and standardized screening of patient-reported outcomes (PROs) has been shown to enhance patient-clinician communication, improve symptom management, reduce health service utilization, and even improve survival. Despite this, PRO programs remain scarce outside of clinical trials. In this symposium, the implementation of real-world PRO programs from across Canada will be presented. Presentations will focus on unique opportunities, challenges, reach, and/or innovations.
Sample and setting: In Canada, there have been “early adopters” of PRO programs, under various stages of implementation, in different cancer care settings and for various patient populations.
Results: In Ontario, the feasibility has been shown for remote symptom monitoring and real-time symptom intensification during systemic treatment. Quebec centres have been working on the implementation of a mobile-based PRO and caregiver-reported outcome (CRO) program, integrating stepped-care clinical pathways. Alberta’s ambulatory oncology model of care integrates PRO-derived symptom complexity score. Dalhousie University’s Radiation Oncology Department is planning widespread electronic platform installation to facilitate PRO adoption across three Atlantic provinces.
Conclusion: Transferrable PRO tools and lessons learned will be shared to inform future PRO program adoption and expansion.
Background/Introduction: Research on symptom complexity among cancer patients is limited and there is no standardized classification to measure it. In Alberta, the Patient Reported Outcomes (PRO) project team proposed and developed a symptom complexity algorithm, derived from validated and standardized PRO measures, to classify symptom complexity at an individual level.
Methods/Program/Innovation: Starting with a random selection of 520 patients who visited the Tom Baker Cancer Centre (TBCC) from October 2018 to November 2018, a symptom complexity algorithm was developed to classify these patients based on the severity of their symptom scores and their problems/concerns reported. This algorithm was then validated with a retrospective chart review with cancer patients who visited a cancer facility in Alberta, Canada from February 2016 to November 2017 (N= 1,466).
Results: Based on established validity and clinical relevance, the PRO derived symptom complexity algorithm was integrated into clinical tools that make the identification of patients who have high or moderate symptom complexity levels easily identifiable. The algorithm acts as a symptom complexity flag, helping healthcare teams identify which patients may need more timely, targeted and individualized symptom management.
Conclusions: The utility of this type of symptom complexity score is broad. It has been used to identify a personalized dose of care that a patient requires (micro); to identify which clinics may benefit from adjustment to their clinical booking templates or additional staffing (meso), or as a component of program capacity planning (macro). Examples like these will be shared in this session.
Remote symptom monitoring and real-time symptom management using digital technology can improve symptoms, quality of life and survival. The Canadian Advanced Symptom Monitoring and Management System (CAN-ASyMS) is one of the most evolved digital technologies for remote daily reporting of PROs followed by back-end risk scoring, automation of self-care advice and alerting of clinicians for intensification of symptom management support using evidence-based decision support tools using pan Canadian triage guidelines. In this sequential, mixed-method randomized clinical trial we tested feasibility and effects of CAN-ASyMS on symptoms, quality of life, healthcare use and self-efficacy outcomes. In this paper, we present the results of remote monitoring and implications for implementation in 'real-world' cancer care.
In this sequential, mixed-method randomized clinical trial we tested feasibility and effects of CAN-ASyMS on symptoms, quality of life, healthcare use and self-efficacy in adjuvant breast and lymphoma cancer patients receiving systemic therapies. Mixed model regressions for repeated measures and t-tests were used to examine effectiveness endpoints. Qualitative interviews were also conducted following the trial and analyzed using content analysis.
A total of 79 patients completed the study and we met our feasibility outcomes. Group differences were shown for quality of life, distress, and symptom outcomes. Participants (n=12) described feeling "safe and secure" and were "reassured" that they were still ‘connected’ to their clinical team. Clinicians described concerns about the number of ‘alerts’ and how these could be managed in current workflow.
Remote monitoring and real time symptom management requires moving beyond implementation to service redesign for sustainability.
Patient-reported outcome (PRO) programs are complex interventions that require extensive clinical resources and stakeholder buy-in, and inevitably change clinical and managerial care processes. The purpose of this presentation is to share the lessons learned of a large collaboration among clinicians, managers, patients, and researchers for the implementation of electronic PROs across cancer centres in Quebec (called e-IMPAQc).
Five adult cancer centres in Quebec have participated in the development of e-IMPAQc over a period of 2 years. Seven working groups were established with representation from each centre to ensure the co-design of key aspects of e-IMPAQc (e.g., PRO measures, evaluation, education, technology, and implementation and change management).
Key lessons learned include, building electronic PRO screening on knowledge gained from paper-based screening (e.g., using same tools) and, where possible, minimize workflow disruption by completing workflow mapping activities. This in turn had implications regarding what was included in the program, and determining what is sufficient in real-world PRO screening vs. best evidence. Support from leadership (local and provincial) and leveraging win-win opportunities facilitated buy-in. The most significant challenge was technology, and lessons learned include understanding what is feasible (vs. possible), developing clear deliverables, monitoring budget, being aware of provincial approval needed to facilitate connections, and ensuring participation of IT in the development. With over 49 stakeholders involved communication was another challenge as well as having a clear governance structure that is maintained.
Findings deliver applicable lessons for development of PRO programs and inform the process of integrating innovations in oncology using real-world evidence.
Increased uptake of distress screening is challenged by a lack of information technology (IT) resources to allow distress screen scores to be captured efficiently and used effectively, either at point of care or within quality improvement (QI) initiatives. Our project allows for expansion of electronic symptom screening for point of care use across three Dalhousie Department of Radiation Oncology (DRO) cancer centres (Halifax and Sydney, Nova Scotia, and Saint John, New Brunswick) and large scale “Big Data” collection and implementation of QI initiatives.
A multidisciplinary team approach helping identify needs for training, testing, and clinical workflow.
Three phased rollouts will be planned for the radiation centres spanning a year (2021-2022) and beginning with a chosen centre (Halifax) and tumor site (Head and Neck) as pilot. CPQR-endorsed screening tools and existing evidence-based care algorithms will be used to start. The implementation of the data analytics tool will occur in Halifax centre and setup to receive distress screening data transmissions each quarter.
Project measures include uptake of screenings, satisfaction rates of training, identification of referrals made as a result of distress screen and prevalence of symptom burden.
Introducing electronic distress screening places data collection into the hands of the patient thereby requiring extensive application training and support for them in addition to the typical staff training needed for new applications. The point of care review of the data builds on current clinical workflow. Data analysis of distress data is to be determined at committee level.
Engaging multi-disciplinary radiotherapy teams in the planning and messaging of the project are key steps in planning. Building from existing CPQR-endorsed deliverables and utilizing evidence-based algorithms and screening tools allows for focus on the technology rollout planning.