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Talk from IPOS 2010
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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
0.20
0.30
0.40
0.50
0.60
0.70
0.80
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
0.00
0.10
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0.40
0.50
0.60
0.70
0.80
0.90
1.00
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