ipos10 t177- implementation of a screening programme for cancer related distress: part i - does...

Alex Mitchell www.psycho-oncology.infoPaul SymondsLorraine GraingerElena Baker-Glenn

Department of Cancer & Molecular Medicine, Leicester Royal Infirmary

IPOS 2010IPOS 2010

T177 - Implementation of a Screening Programme for Cancer Related Distress:

Part I - Does Screening Influence Detection of Distress?

T177 - Implementation of a Screening Programme for Cancer Related Distress:

Part I - Does Screening Influence Detection of Distress?

Concepts of ImplementationConcepts of Implementation

Staff Recognition (unassisted)

Tool Validity (vs gold standard)

Tool acceptability

DetectionClinician managementPatient wellbeing

Before tool

After tool

Pilot tool

Baseline

Audit / Research ProtocolAudit / Research Protocol

Phase I – DT across LNR network (incl training)

Phase II – Enhancements to DT

Phase III - Screening plus Intervention

Phase I

Phase II

Phase II

0.00

0.10

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0.50

0.60

0.70

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0.90

1.00

DistressThermometer

AnxietyThermometer

DepressionThermometer

AngerThermometer

TenNineEightSevenSixFiveFourThreeTwoOneZero

Comment: Slide illustrates scores on ET tool

8%

DT37%

DepT23%

AngT18%

AnxT47%

4%

7%

1%

1%

9%

3%

0%

2%

4%

15%

3%

2%

Nil41%

Non-Nil59%

DT

AnxT AngT

DepT

More than just “distress”More than just “distress”

Of 401 chemotherapy attendees

59% have an emotional complication (3v4)

37% (62% of 59%) it included distress

23% it excluded distress

Validity of DT vs depression (DSMIV)

SE 80% SP 60% PPV 32% NPV 93%

Of 64 DSM-MDD 50 +ve on DT

800 Patients Approached

100 Not Willing (13%) 700 Patients Willing (87%)

500 Staff Willing (71%)TAU

402 Data Collected (80%)Screen Data

Leicester: DT/ET ImplementationLeicester: DT/ET Implementation T177 t680

Detections before Detections after Care after

Phase II Results – detection baselinePhase II Results – detection baseline

Comment: Slide illustrates diagnostic accuracy according to score on DT

11.815.4

30.4 28.9

41.9 42.9 40.7

57.1

82.4

66.771.4

15.8

25.0

26.124.4

19.4 19.0

33.3

21.4

11.8

22.2 14.3

72.4

59.6

43.546.7

38.7 38.1

25.921.4

5.911.1

14.3

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Zero One Two Three Four Five Six Seven Eight Nine Ten

Judgement = Non-distressedJudgement = UnclearJudgement = Distressed

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0.90

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0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Pre-test Probability

Pos

t-tes

t Pro

babi

lity

CHEMO+

CHEMO-

Baseline Probability

COMMU+

COMMU-

Detection sensitivity = 50.6%Detection specificity = 79.4%Overall accuracy = 65.4%.

Comment: Slide illustrates performance of chemotherapy vs community nurses in oncology

Phase II Results Post ET (DT)Phase II Results Post ET (DT)

1. Does tool influence detections?

2. Does tool influence quality of care?

Pre-Post Screen - DistressPre-Post Screen - Distress

Before After

Sensitivity of 49.7%

Specificity of 79.3%

PPV was 67.3%

NPV was 64.1%

Pre-Post Screen - DistressPre-Post Screen - Distress

Before After

Sensitivity of 49.7% 55.8% =>+5%

Specificity of 79.3% 79.8% =>+1%

PPV was 67.3% 70.9% =>+4%

NPV was 64.1% 67.2% =>+3%

There was a non-significant trend for improve detection sensitivity (Chi² = 1.12 P = 0.29).

Screening a failure?Screening a failure?

Clover, Carter et al (unpublished)

0

5

10

15

20

25

30

35

1 2 3 4 5 6 7 8Quarter of screening

% p

atie

nts

over

thre

shol

d Distress

Pain

First occasion of screening (n=4543)

a. Communicationa. Communication

DISTRESS

43% of CNS reported the tool helped them talk with the patient about psychosocial issues esp in those with distress

28% said it helped inform their clinical judgement

DEPRESSION

38% of occasions reported useful in improving communication.

28.6% useful for informing clinical judgement

Credits & Acknowledgments

Elena Baker-Glenn University of NottinghamPaul Symonds Leicester Royal InfirmaryChris Coggan Leicester General HospitalBurt Park University of NottinghamLorraine Granger Leicester Royal InfirmaryJames Coyne University of PennsylvaniaNadia Husain Leicester General HospitalJoanne Herdman Leicester General HospitalJo Kavanagh Leicester Royal Infirmary

For more information www.psycho-oncology.info