Krzyzanowska Monika K, MacKay Cassandra, Han Heekyung, Eberg Maria, Gandhi Sonal, Laferriere Nicole B, Powis Melanie, Howell Doris, Atzema Clare L, Chan Kelvin K W, Kukreti Vishal, Mitchell Sandra, Nayer Marla, Pasetka Mark, Knittel-Keren Dafna, Redwood Erin
1Cancer Care Ontario, Toronto, ON Canada.
2University Health Network, Toronto, ON Canada.
Pilot Feasibility Stud. 2019 Mar 8;5:39. doi: 10.1186/s40814-019-0404-y. eCollection 2019.
Chemotherapy is associated with a significant risk of toxicity, which often peaks between ambulatory visits to the cancer centre. Remote symptom management support is a tool to optimize self-management and healthcare utilization, including emergency department visits and hospitalizations (ED+H) during chemotherapy. We performed a single-arm pilot study to evaluate the feasibility, acceptability, and potential impact of a telephone symptom management intervention on healthcare utilization during chemotherapy for early stage breast cancer (EBC).
Women starting adjuvant or neoadjuvant chemotherapy for EBC at two cancer centres in Ontario, Canada, received standardized, nurse-led calls to assess common toxicities at two time points following each chemotherapy administration. Feasibility outcomes included patient enrollment, retention, RN adherence to delivering calls per the study schedule, and resource use associated with calls; acceptability was evaluated based on patient and provider feedback. Impact on acute care utilization was evaluated post hoc by linking individual patient records to provincial data holdings to examine ED+H patterns among participating patients compared to contemporaneous controls.
Between September 2013 and December 2014, 77 women were enrolled (mean age 55 years). Most commonly used regimens were AC-paclitaxel (58%) and FEC-docetaxel (16%); 78% of patients received primary granulocyte colony-stimulating factor prophylaxis. 83.8% of calls were delivered per schedule; mean call duration was 9 min. The intervention was well received by both patients and clinicians. Comparison of ED+H rates among study participants versus controls showed that there were fewer ED visits in intervention patients [incidence rate ratio (IRR) (95% CI) = 0.54 (0.36, 0.81)] but no difference in the rate of hospitalizations [IRR (95% CI) = 1.02 (0.59, 1.77)]. Main implementation challenges included identifying eligible patients, fitting the calls into existing clinical responsibilities, and effective communication to the patient's clinical team.
Telephone-based pro-active toxicity management during chemotherapy is feasible, perceived as valuable by clinicians and patients, and may be associated with lower rates of acute care use. However, attention must be paid to workflow issues for scalability. Larger scale evaluation of this approach is in progress.
化疗具有显著的毒性风险，这种风险通常在患者前往癌症中心门诊就诊的间隔期达到峰值。远程症状管理支持是一种优化自我管理和医疗资源利用的工具，包括在化疗期间减少急诊科就诊和住院次数（ED+H）。我们开展了一项单臂试点研究，以评估电话症状管理干预措施对早期乳腺癌（EBC）化疗期间医疗资源利用的可行性、可接受性及潜在影响。
在加拿大安大略省的两个癌症中心，开始接受EBC辅助或新辅助化疗的女性患者，在每次化疗给药后的两个时间点，会接到由护士主导的标准化电话，以评估常见毒性。可行性结果包括患者入组、留存情况，护士按照研究计划拨打随访电话的依从性，以及与电话相关的资源使用情况；基于患者和医护人员的反馈评估可接受性。通过将个体患者记录与省级数据记录相链接，对参与研究的患者与同期对照患者的急诊和住院模式进行比较，事后评估该干预措施对急性护理利用的影响。
2013年9月至2014年12月期间，77名女性患者入组（平均年龄55岁）。最常用的化疗方案是AC-紫杉醇（58%）和FEC-多西他赛（16%）；78%的患者接受了一级粒细胞集落刺激因子预防性治疗。83.8%的电话按计划拨打；平均通话时长为9分钟。该干预措施受到患者和临床医生的好评。研究参与者与对照患者的急诊和住院率比较显示，干预组患者的急诊就诊次数较少[发病率比（IRR）（95%CI）=0.54（0.36，0.81）]，但住院率无差异[IRR（95%CI）=1.02（0.59，1.77）]。主要的实施挑战包括确定符合条件的患者、将电话随访纳入现有的临床工作安排，以及与患者的临床团队进行有效沟通。
化疗期间基于电话的主动毒性管理是可行的，临床医生和患者都认为其有价值，并且可能与较低的急性护理使用率相关。然而，为了扩大规模，必须关注工作流程问题。目前正在对这种方法进行更大规模的评估。
