Managing symptoms in cancer patients remains a challenge for providers, especially for ethnic minority (REM) populations who often face health disparities that can negatively impact their health outcomes.
PROBLEM
Therefore, over the years, many researchers have evaluated whether electronic tools can help in early recognition of symptoms.
However, these studies are:
- Primarily applicable to a predominantly non-Hispanic white population.
- Rarely is there involvement of allied health professionals (such as pharmacists) as a resource for symptom management with electronic patient-reported outcome (ePRO) outcomes.
- Multilingual tools are rarely integrated, which is especially important in REM.
“Pharmacists often have difficulty detecting health problems early due to limited knowledge of their patients’ health or poor communication due to language barriers, which are very common problems in people in REM,” said Alexandre Chan, chair and professor of clinical pharmacy practice at UC Irvine.
PROPOSE
UC Irvine decided to intervene based on a scientific framework supported by the National Institute on Minority Health and Health Disparities (NIMHD), which advocates for a multidisciplinary and multilevel approach to addressing health disparities.
“Improving early recognition of health problems in REM may also facilitate timely interventions,” Chan explained. “Our results suggest that the use of multilingual ePROs for symptom management, led by oncology pharmacists, has the potential to address many of the health disparities faced by REM patients.
“And with REM patients more likely to report certain symptoms – such as pain, nausea and vomiting – our results highlight that using ePROs could identify these symptoms early, helping to reduce disparities in symptom severity and health outcomes.”
Facing the Challenge
Adult patients 18 years of age and older who were newly diagnosed with cancer and receiving intravenous cancer treatment at the Chao Family Comprehensive Cancer Center at UCI Health in Orange were evaluated for inclusion in the study.
Eligible patients were screened through the oncology pharmacist’s pharmacy schedule in the electronic health record. The multi-level intervention incorporated ePRO measures to support oncology pharmacists in symptom management in patients undergoing cancer treatment. There were three components to the intervention.
“First, screen for symptoms using ePRO,” Chan said. “Standardized ePRO assessments are performed through REDCap using computer adaptive tests (CATs). Patients are given a dedicated iPad before or during their infusion and complete their assessments at the infusion chair. ePRO includes Patient Reported Outcomes Measurement Information System (PROMIS) measures developed by the National Institutes of Health.
“Our EPRO measured seven health domains: nausea and vomiting, physical impairment, anxiety, depression, fatigue, cognitive impairment, and pain interference,” he continued. “All domains were administered as CATs, except for nausea and vomiting. The measures were chosen to comprehensively assess treatment toxicity and physical, mental, and social well-being.
Patient demographic characteristics, responses to each PROMIS item, and data on PROMIS utilization were also recorded.
“Both English and Spanish are available,” Chan notes. “When a particular language—such as Vietnamese or Korean—is not available, we employ medical interpreters via remote video technology. After a patient completes the ePRO, the raw score is converted into a severity level (normal, mild, moderate, and severe) based on a standardized threshold in real time.”
The second component is symptom management performed by trained oncology pharmacists.
“An oncology pharmacist immediately reviewed the symptom screening results and provided personalized symptom management and treatment advice to the patient, consistent with current requirements under the ASCO QOPI certification program standards,” he said.
“Participating pharmacists attended a live training session to understand the workflow and review existing care pathways,” he added. “In addition, pharmacists were able to communicate and document treatment decisions, including medication prescribing, with other members of the cancer care team via the EHR.”
And the third component is the study summary and patient follow-up. After each visit, patients were asked about their satisfaction and acceptability of the program. Satisfaction was assessed with a single item: “How satisfied are you with the counseling services provided by the pharmacist?” on a 5-point Likert scale (very dissatisfied to very satisfied) adapted from similar studies.
“The acceptability of the ePRO and education session durations was assessed similarly,” Chan explains. “Finally, based on the pharmacist’s assessment of patient symptoms, participants were either discharged from the study by mutual agreement or followed up at a follow-up visit. This allowed the pharmacist to reassess the patient’s symptoms, provide additional intervention, and/or provide counseling as needed.
“By facilitating symptom reporting and intervention, reducing language barriers, and improving communication, our intervention shows potential to address health disparities at multiple levels, such as the individual and interpersonal,” he continued. “Importantly, our racial/ethnic distribution paralleled the demographic characteristics of the county where the study took place, and patients across racial/ethnic groups expressed a desire to continue the intervention through multiple visits at similar rates.”
RESULT
By implementing an intervention that included an electronic patient outcomes reporting tool combined with digital analytics, racial/ethnic minorities (Hispanic/Latinx and Asian patients) receiving chemotherapy at the Chao Family Comprehensive Cancer Center (a majority minority cancer center) were twice as likely to report pain and twice as likely to report nausea and vomiting compared to non-Hispanic whites.
Chan said these findings could be seen elsewhere where REM patients diagnosed with cancer are being treated.
“In addition, we also observed that Hispanic/Latinx patients were twice as likely to use urgent care as non-Hispanic white patients,” he noted. “This was also true for patients of other ethnicities – they were four times more likely to use urgent care than non-Hispanic white patients.
“Using the intervention, oncology pharmacists are also able to personalize our patient care,” he continued. “With 90% of patients expressing satisfaction, our ePRO-driven intervention, led by oncology pharmacists, has facilitated symptom assessment and management.”
ADVICE FOR OTHERS
Chan recommends that healthcare providers consider how their tools (if they are developing them) can personalize care if they are facing similar issues.
“In addition to integrating into the electronic health record, they also need to think about whether they can engage pharmacists and providers on-site to provide timely and immediate personalized symptom management,” he concludes. “In addition, it is important to engage providers to ensure the organization understands the needs of providers.”
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