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Implementing psychosocial care into routine practice:

Making it easyinto routine practice: Making it easy

Prof Phyllis ButowSchool of Psychology &

Chair, Psycho-Oncology Co-operative Research Group (PoCoG)

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Prevalence of distress

Mehnert A et al. JCO 2014; 32: 3540-3551

• Prevalence of distress in cancer patients is HIGH

• Recent definitive study in Germany of in- and out-patients

• Stratified proportional sampling - appropriate representation of all tumour types

• 4020 patients (68% response rate)

• Patients scoring above 9 on PHQ interviewed with CIDI-O

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4-week prevalence of mental disorder

Disorder Prevalence (%) 95% CI (%)Mental disorder 32 29 - 34Anxiety 12 10 - 13Mood disorder 7 6 -8Adjustment disorder 11 10 -12

Mehnert A et al. JCO 2014; 32: 3540-3551

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Efficacy of interventions

› We know interventions are effective

› Recent meta-analysis: 198 studies - 22,238 patients

› Significant small-to-medium effects for individual and group psychotherapy and psycho-education

- Larger effects if high distress patients recruited

› Effects sustained, in part, in the medium (< 6 months) and long term (> 6 months)

Faller H et al. JCO 2013; 31(6):782-93

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Guidelines in psychosocial care

Screening and management

Screening patients with cancer for anxiety and depression is widely recommended internationally

Early detection and treatment: Reduces patient suffering and the likelihood of

developing a major mood disorder Improves quality of life Reduces health service utilisation

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• Howell etal (2010), Canadian Association of Psychosocial Oncology: Toronto, • NCCN, Clinical Practice Guidelines in Oncology. Distress Management Version 2. • Andersen (2014) Screening, Assessment, and Care of Anxiety and Depressive Symptoms

in Adults With Cancer: ASCO Guideline Adaptation. • Howell et al (2011) Current Oncology,

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What happens in practice?

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PoCoG review of screening for distress in Australia and Internationally

› Review of the literature

› Structured interviews with:- Key stakeholders from US, Canada, Netherlands, UK and

Australia- Clinicians, Representatives of Health Departments and

Cancer Councils

Commissioned by Cancer Australia

Actual practice…

Screening not routinely conducted in Australia Emotional symptoms commonly undetected, severity

under-estimated

Reasons for not screening? Lack of confidence, insufficient training Time pressures Lack of psychosocial staff and referral guidance - what

to do if someone is identified through screening?

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Mitchell et al., Psych-oncology , 2008; Absolom etal., Psycho-oncology 2011

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Screening not the complete answer

Distress screening rates in Canada, 2008-2012

Despite this, psychosocial outcomes not improved

Howell D et al, Pall and Supp Care 2014

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› US and UK data show many oncology health professionals- Do not value screening data- Do not respond to it

› Patient referral

remains adhoc

Jacobson P et al, 2007Mitchell A et al, 2012; 2011

Screening data is not used

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› Synthesis of data from 40 years of screening in the primary care setting shows that:

› Screening alone does not improve patient outcomes

› A clear clinical pathway, with institutional commitment, is required

› Mitchell A et al, 2011

Screening not the complete answer

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PoCoG Clinical Pathway for Anxiety and Depression

PoCoG developed an evidence-based clinical pathway for identifying and managing anxiety and depression in cancer patients

Development guided by: existing empirical evidence wide stakeholder consultation

in-depth clinician interviews a delphi process with 87 multidisciplinary stakeholders

Shaw J, Price M et al. Supportive Care in Cancer 2015

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PoCoG pathway

› Process of stakeholder involvement designed to ensure engagement

› Gaining multi-disciplinary perspectives designed to ensure the pathway is acceptable to all groups

› Pathway designed to provide clear and detailed guidance

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Methods

Conducted a two-round, on-line Delphi study

Round 1: 39 statements across 6 domains Scoring:

Statements rated 1 (strongly disagree) to 5 (strongly agree) Free text comments to justify response

Consensus defined as 80% or more of respondents rating the item within two points on the scale

In round 2, participants re-rated statements that failed to gain consensus in light of the overall group responses

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Participants Participants:

87 clinically active members of PoCoG from a range of disciplines: Medical and radiation oncologists, nurses,

psychologists, social workers, palliative care physicians, psychiatrists, GPs and cancer surgeons

Rural/regional and metropolitan regions across all states Range of practice settings

Public/private Tertiary referral centres, regional hospitals Outpatient/community services

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Results – key findings

ScreeningBroad agreement Pathways should be tailored for local implementation based

on local resources as well as patient characteristics Screening should be routinely implemented and formalised Designated staff member should be responsible

No consensus on specific methods of screening Two step process Edmonton Symptom Assessment System (ESAS) Who is most appropriate to conduct screening

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Results – key findings

Assessment and ReferralBroad agreement Further assessment to clarify the nature and severity of

anxiety/depression Need to accommodate patient treatment preferences Need for patient education to maximise uptake of services

No consensus on: Whether screening and subsequent assessment should be

carried out simultaneously by the same staff member or sequentially

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Results – key findings

Stepped Care Clinical PathwayBroad agreement Stepped care model for managing anxiety/depression is

appropriate

No consensus on: Whether practical and spiritual issues should be

included in the pathway Inclusion of treatment time frames

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Results-key findingsMonitoring and Care CoordinationBroad agreement Responsibility for coordination of care will depend on local

staffing, resources, patient factors and preferences Ongoing monitoring and follow up:

Lower levels of distress: nurses, oncologists and GPs responsible

Higher levels: specialised mental health professionals take on responsibility

No consensus on: Who should be responsible for coordination of care for

anxiety/depression

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Conclusions

Our results confirmed: Overall support for the clinical pathway Support for routine formal screening of

anxiety/depression in oncology Support for stepped-care model of treatment and review Need for flexibility in pathway implementation

Lack of consensus on specific screening methods and roles for management and co-ordination of care

The Pathway:

Is flexible and tailored to each site Incorporates screening, referral and management

recommendations Provides timing for follow up Suggests roles and responsibilities Utilises a stepped care model

5 steps from minimal to severe anxiety/depression Patients receive least intensive intervention likely to

be effective More intensive interventions reserved for patients

who do not benefit from simpler first line treatments

Clinical Pathway

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Can we get this clinical pathway into routine practice?

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Lack of research into “The gap”

› Despite an increase in intervention studies, there is a serious lack of implementation / dissemination studies

› <6% of studies aim to close gap between evidence and clinical practice

› Bryant J, Boyes A, Jones K, et al: Examining and addressing evidence-practice gaps in cancer care: a systematic review. Implement Sci 9:5908-9, 2014

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PARiHS framework

Barriers analysis

- How can we implement the pathway?

- Qualitative interviews: - Expert opinion elicited via audio-recorded semi-structured

interviews - 12 multi-disciplinary clinicians

- Transcribed, coded and analysed

- Rankin N, Butow P et al. BMC Health Services Research, 2014

Resources› Lack of time, staff, resources, facilities › No agreement on screening tools & cut off scores

Responsibility› Who screens? Assesses? Refers?› Ethical responsibility of detecting distress

Staff barriers

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Enabling implementation

Engagement“…Engagement with psychosocial services and the nursing staff as a starting point is really important because ... at the end of the day they’re going to implement it.”

Education and training“(You) have to … offer training to the oncologists and nursing staff in terms of basic psycho-education and... have some simple resources that could be provided to patients.”

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Enabling implementation

Evidence-based, and will make their life easier“Widespread education that highlights both the importance of psychosocial assessment, as well as the efficacy of intervention(s)

“... how it reduces clinician time by identifying and intervening with psychological distress in a timely manner.. and .. prevents unnecessary admissions and presentations, as well as improving quality of life and satisfaction with care

“…how this improves the clinical life for the coal-face oncologist. And how it improves the quality of life of patients and their carers”

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Patient barriers

Patient reluctance› Stigma of mental health care› Feel embarrassed they are not coping› Don’t want to burden cancer care team› Feel they are not bad enough to warrant care, have enough support

at home

“For a lot of people, it’ll be the first time they’ve ever spoken to someone about distress, so it’s not a simple step”

“There’s a great resistance with some people... there’s one gentleman … who is just refusing point blank to see anybody, yet his wife is telling me that he’s spending most of his time in tears at home....”

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Patient reluctance

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Enabling intervention

› Patient resources- Booklets and internet sites that normalise psychological morbidity and care

› Staff training in making an effective referral- Role-play, online resources

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System barriers and solutions

Culture of health services“there needs to be explicit support from the institution that spending time on these issues is time well spent. That it’s valued and supported, people are given time to do it, and that it is a priority...so that everybody’s engaged in this being an important service initiative…”

Change management“It needs to be system level intervention where these things are …integrated, in routine documentation, in IT systems and in quality review.”

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Enabling implementation

Adoption into health policy at state and local level

“ I think one of the things that might help you, though... the funding they get for cancer services from the NSW health department ... there’s key KPIs that they have to meet…

And if something like this was built into the memorandum of understanding ... it means that... at local district level you’ve got senior buy in to say ‘this is an expectation of our cancer services”

CINSW Translational Program Grant

OVERALL AIMS

• Facilitate the integration of the clinical pathway for anxiety and depression in cancer patients into routine care

• Develop and evaluate implementation strategies to promote uptake of pathways in the Australian health context.

Chief Investigators Associate Investigators

› Prof Phyllis Butow› Prof Gavin Andrews› Prof Afaf Girgis› Prof Brian Kelly› Prof Tom Hack› A/Prof Josephine Clayton› Dr Melanie Price› A/Prof Philip Beale› Prof Rosalie Viney› Dr Laura Kirsten

+ Consumer advisory group

› Dr Joanne Shaw› Dr Haryana Dhillon› Dr Joseph Coll› Dr Peter Grimison› Prof Tim Shaw› Dr Nicole Rankin› Dr Michael Murphy› Dr Jill Newby› Mr John Stubbs› Dr Frances Orr› Dr Toni Lindsay

Wide expertise

Clinical partners› Four Cancer Institute NSW Translational Cancer Research

Centres (TCRCs) - Sydney Catalyst - Centre for Oncology Education and Research Translation - Sydney Vital - Sydney West-

- TCRCs are networks of clinical and research teams- Will encourage buy-in and engagement- Will champion the work

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How will we address barriers?

Target Barrier StrategyAdministration / Leaders

Lack of support • Appoint clinical and administrative champions

• Involve TCRCs• CINSW backing

General Oncology staff

Lack of team ownership

Involve key staff from all disciplines in tailoring the pathway to their context

Lack of education re why and how

Online educational resources with role-play demos and cases:• Empathic communication• How to screen• How to make a referral (Especially if patient reluctant) Available on EVI-Q and at point of contact, with annual reminders to review

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Educational resources;

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Target Barrier StrategyGeneral Oncology staff Lack of time Automated system which:

• Cues patient to complete online assessment at baseline and follow-up

• Provides graph of scores over time• Sends email to staff when patient is

over cut-off, for further assessment• Provides links to referral template• Emails referral to pre-specified staff• Is linked to electronic records if possible

(eg MOSAIQ)

Psychosocial staff Lack of time Develop online cognitive-behavioural therapy to which mild to moderate cases can be referred• Keeps staff informed of progress• Staff cued if further intervention neededEncourage wider referral options

How will we address barriers?

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Online therapy

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Target Barrier StrategyPatients • Stigma

• Reluctance to burden staff

Patient written and online resources:

• Explain anxiety and depression• Normalise • Note part of routine care• Provide a lay version of the pathway

Train staff to screen and refer well

How will we address barriers?

Research programme

› A cluster randomized controlled trial (RCT) to evaluate the cost and efficacy of:

- an intensive, tailored implementation strategy - versus - a basic implementation strategy

for the anxiety and depression clinical pathway

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All sites

› Access to all the health professional, patient and system resources

› On-site briefing session on pathway and systems

› Posters advertising the program

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Intervention sites

› Training and ongoing support of local champions

› Audit and feedback prior to and midway through the intervention

› Face-to-face education regarding the portal and online tools which support the pathway

› Facilitated tailoring of the pathway to the local setting

› IT support

› Other strategies to address the specific barriers and facilitators in each site

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The outcome?

› We hope:

- The clinical pathway will remain in use- Improved knowledge about implementing health practice change

- Ultimately, better outcomes for patients

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IN SUMMARY

› If we are to really improve psychosocial outcomes, we need proven interventions, clinical pathways,

› AND

› Careful attention to implementation

› It is not easy, but it can be done!

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Or we could…