Vol. 49 No. 5 May 2015
Journal of Pain and Symptom Management 939
Brief Report
The Frequency and Factors Associated With the Use of a Dedicated Supportive Care Center Telephone Triaging Program in Patients With Advanced Cancer at a Comprehensive Cancer Center Lindsey E. Pimentel, BSN, RN, CHPN, Sriram Yennurajalingam, MD, Gary Chisholm, MS, Tonya Edwards, MS, RN, CCRP, Maria Guerra-Sanchez, BSN, RN, CCRP, Maxine De La Cruz, MD, Kimberson Tanco, MD, Marieberta Vidal, MD, and Eduardo Bruera, MD Department of Palliative Care and Rehabilitation Medicine (L.E.P., S.Y., T.E., M.G.-S., M.D., K.T., M.V., E.B.) and Department of Biostatistics (G.C.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
Abstract Context. There is limited literature on characteristics of telephone triage programs and the nature of interventions in palliative care. Objectives. Our aim was to determine frequency and type of care provided by a Supportive Care Center Telephone Triaging Program (SCCTP) in advanced cancer patients (ACPs). Methods. Electronic medical records were reviewed of 400 consecutive ACPs referred to palliative care at a comprehensive cancer center and given access to the SCCTP: 200 from the outpatient (OP) supportive care center and 200 from inpatient (IP) palliative care given access after discharge. We reviewed call frequency, type, reason, and outcomes including pain and other symptoms (Edmonton Symptom Assessment Scale and Memorial Delirium Assessment Scale [MDAS]) associated with utilization of the SCCTP. Results. A total of 375 patients were evaluable. One hundred fifteen of 400 patients (29%) used the SCCTP: 96 OPs (83%) used the SCCTP vs. only 19 IPs (17%) (P < 0.001). The most common reasons for calls were pain (24%), pain medication refills (24%), and counseling (12%). For 115 phone calls, 43% (145 of 340) of recommendations were regarding care at home and 56% were regarding opioids. Patients who used the SCCTP had worse pain (P ¼ 0.006), fatigue (P ¼ 0.045), depression (P ¼ 0.041), and well-being (P ¼ 0.015) and better MDAS scores (P ¼ 0.014) compared with nonusers. OPs had a higher prevalence of symptom distress (P ¼ 0.013), depression (P < 0.001), anxiety (P < 0.01), and insomnia scores (P ¼ 0.001); MDAS scores were significantly higher in IPs (P < 0.001). Conclusion. In this study, we found that overall utilization of the SCCTP by ACPs referred to palliative care was relatively low at 28.7%. The use of the SCCTP was particularly poor among the IPs on discharge. Patients who used SCCTP had worse pain, fatigue, depression, and well-being scores and better delirium scores. J Pain Symptom Manage 2015;49:939e944. Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved. Key Words Outpatient palliative care, nurse telephone triage, phone care, supportive care, symptom control
Introduction Palliative care patients experience severe physical and psychosocial symptoms.1,2 These symptoms significantly impact the quality of life of patients and Ms. Pimentel and Dr. Yennurajalingam contributed equally to this work. Address correspondence to: Eduardo Bruera, MD, Department of Palliative Care and Rehabilitation Medicine, Unit 1414, The University of Texas M. D. Anderson Cancer Center, Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
caregivers.3,4 Although most patients receive palliative care in an inpatient (IP) setting, of late a growing portion of patients have been receiving care as outpatients (OPs).5 This is partially a result of longer
1515 Holcombe Boulevard, Houston, TX 77030, USA. E-mail: [email protected] Accepted for publication: October 22, 2014.
0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2014.10.020
940
Pimentel et al.
Vol. 49 No. 5 May 2015
survival seen in patients with advanced cancer and also may result from early referral.6e9 However, many palliative care patients often receive less than two follow-up visits,10,11 perhaps because of worsening symptoms, deteriorating health status, and/or logistical reasons that make adherence to OP supportive care center follow-up visits more difficult. Therefore, because of the increased symptom burden in the advanced cancer patient population, ongoing symptom management for patients receiving palliative care is vital.7,11 Previous studies have suggested that nurse-led telephone triage to improve access to care between physician visits and early symptom management are crucial to providing care to all patients, particularly those with advanced cancer.12,13 However, there is limited literature on the characteristics of telephone triage programs and the nature of interventions.14e17 At The University of Texas M. D. Anderson Cancer Center, palliative care and symptom control is offered in both the IP and OP settings. Patients are referred for management of uncontrolled physical symptoms (pain, fatigue, nausea and vomiting, loss of appetite, and sleep), emotional distress (anxiety, depression, and coping), and to assist with transitioning from curative to palliative care.11,18 The purpose of this study was to describe the frequency and type of telephone calls made by patients and their caregivers to our OP Supportive Care Center Telephone Triaging Program (SCCTP) and the various nursing interventions made during these telephone interactions. We also examined the effect of the SCCTP on pain control and on Edmonton Symptom Assessment Scale (ESAS) symptoms and counseling needs in patients seen by the palliative care service as IPs compared with OP consultations. We hypothesized that OP consultations would use the SCCTP more than IP consultations; patients with high ESAS symptom scores would have increased use, which would lead to decreased symptom distress.
excluded. In total, of the 400 eligible patients, 375 patients were evaluable (n ¼ 200 OP, n ¼ 175 IP). Twenty-five IPs were not evaluable as they expired before discharge from the hospital.
Methods
CAGE Questionnaire. The CAGE Questionnaire is a simple four-item screening survey for alcoholism. CAGE ‘‘positive’’ patients have a higher risk of chemical coping22e24 and require more intense interdisciplinary care.
In this retrospective study, we examined 200 consecutive IPs seen as consultations by the palliative care mobile team (IP) and 200 consecutive OPs seen at the supportive care center (OP) for six months beginning March 12, 2012. Consults were followed for six months from initial contact with palliative care to assess the number of patients who used the SCCTP and the number of calls made by these patients. Information regarding telephone calls from telephone records was systematically collected by OP clinic nurses assigned to telephone triaging each day in the supportive care center. Patients who had previously been seen by the palliative care team were
Process of SCCTP At initial consultation, patients and families receiving palliative care at the OP and IP were educated about the availability of the SCCTP weekdays during clinic hours. Patients and their families were encouraged to call the SCCTP for any issues or concerns regarding palliative care needs on discharge. This was reinforced by providing a visiting card that had instructions including telephone numbers to call the SCCTP. The SCCTP was provided at the OP by a total of five palliative care-trained nurses. All these nurses were highly experienced supportive care nurses who worked daily with palliative care faculty and were very familiar with the administration of the assessment of tools, including the ESAS and the Memorial Delirium Assessment Scale (MDAS), management of medications, and counseling. However, no specific cross-validation was conducted as this study was based on practical clinical care.
Standardized Palliative Care Assessments Edmonton Symptom Assessment Scale. Our team previously designed the ESAS to determine the severity of 10 symptoms commonly experienced by cancer patients during the previous 24 hours; these symptoms are pain, fatigue, nausea, depression, anxiety, drowsiness, dyspnea, anorexia, insomnia, and feelings of well-being.19 The severity of each symptom is rated on a numerical scale of 0e10 (0 ¼ no symptom and 10 ¼ worst possible severity). The ESAS is both valid and reliable in the assessment of the intensity of symptoms in cancer patients.19,20 The ESAS Symptom Distress Score is the sum of ESAS pain, dyspnea, appetite, nausea, fatigue, drowsiness, anxiety, depression, and well-being scores.21
Memorial Delirium Assessment Scale. The MDAS is a structured, 10-item, 0e3 clinician-rated scale (possible range 0e30) designed to quantify the severity of delirium in medically ill patients. This tool was originally tested in a heterogeneous population of cancer and noncancer patients. The MDAS has been used and validated for screening and diagnosis of delirium in cancer patients.25
Vol. 49 No. 5 May 2015
Use of a Dedicated Supportive Care Center Phone Triaging Program
Other Data. The following data were collected: number of calls made by each patient receiving palliative care, reason for the call, and recommendations provided by the SCCTP phone nurse. Telephone calls received were grouped into two categories: interventional and logistical. Interventional needs included management of cancer-related symptoms, such as pain, fatigue, nausea/vomiting, anxiety/depression, appetite, constipation, shortness of breath, sleep, confusion/delirium, and counseling needs. Counseling needs were further categorized into family issues, anxiety/depression, disease state/ progression, hospice information/education, and medication education. Logistical needs addressed over the telephone included medication refills, scheduling, rehabilitation/home health orders, prior authorizations, and interdisciplinary issues/coordinating care. The study also evaluated the nature of each patient call and the necessary nursing interventions made during the telephone interaction. We received institutional review board approval for the conduct of this study.
Statistical Considerations All demographics and outcomes, including frequency and type of interventional calls, were described for both the IP and OP populations using descriptive statistics and graphs, and comparisons were performed using t-tests and Chi-squared tests. To obtain an adequate power, we anticipated 136 (34%) of the 400 patients to be callers and 264 to be noncallers. We used a two-sample t-test to compare the callers and noncallers when alpha ¼ 0.05, so as to achieve 80% power to detect an effect size as small as 0.3 for ESAS pain. Comparison of SCCTP utilization between the two populations (IP and OP) was performed with Poisson regression using time in study (until death, lost to follow-up, or end of study) as an offset. A Poisson regression of call counts on the patient population (200 IPs and 200 OPs) was used so as to obtain a 94% power at a 0.05 significance level to detect a response rate ratio of at least 1.4.
Results A total of 375 patients were evaluable. One hundred fifteen of the 400 patients used the SCCTP. Of the 115 users, 96 (83%) were from OP vs. 19 (17%) from IP (P < 0.001). Fifty-seven percent (65 of 115) of users made more than one call and 89% (58 of 65) were from the OP. Sixty-nine of 115 calls were for interventional needs and 86% (60 of 69) were from the OP group. Forty-five of 115 calls were for logistical needs. We found no significant difference in the patient characteristics of those patients who used the SCCTP vs.
941
those who did not (Table 1). The median age of the patient population was 59 years, 55% were females, and 71% were whites. The most prevalent cancer diagnoses were gastrointestinal (20%) and thoracic (19%). Reasons for utilization of the SCCTP were classified into 14 categories (Fig. 1). The most common reasons for calls were for pain and pain medication refills (each 24%). The second most common reason for calling was for counseling needs (12%). For the 115 telephone calls, a total of 340 recommendations were made (Table 2); 43% (145 of 340) were regarding care at home and 55.6% of these recommendations were regarding management of opioids. There was no significant difference in patient characteristics between frequent (more than one call) and nonfrequent (one call) callers; however, when comparing frequency of calls among patients who used the SCCTP, a higher pain score rating was noted in patients with more than one call. Patients who used SCCTP had better MDAS scores (P ¼ 0.014), and worse pain (P ¼ 0.006), fatigue (P ¼ 0.045), depression (P ¼ 0.041), and feeling of well-being (P ¼ 0.015) scores compared with nonusers. OPs had a significantly higher prevalence of CAGE positivity (28% OPs vs. 11% IPs, P < 0.001), symptom distress (P ¼ 0.013), depression (P < 0.001), anxiety (P < 0.01), and sleep (P ¼ 0.001); MDAS scores were significantly higher in the IPs (P < 0.001).
Discussion In this study, we describe the characteristics of a nurse telephone triage program (SCCTP) in an OP supportive care clinic aimed to complement the interdisciplinary care provided at our clinic by our trained palliative care team so as to improve the quality of life in patients with advanced cancer. We found that the overall use of the SCCTP was relatively low at 28.7%, despite the fact that most patients with advanced cancer were having severe symptom distress and were followed up by supportive care. The use of the SCCTP was particularly poor among the IPs seen in consultation by the Palliative Care Mobile Team. There are a number of possible explanations for this, including shorter length of follow-up, higher frequency of delirium, and perhaps less familiarity of IPs compared with OPs with the OP supportive care center, the site from where SCCTP calls are made (Table 1).26,27 Our results suggest that much more education, such as brochure, a short film, or reminders, are necessary especially among the IPs who are discharged and their caregivers so as to encourage them to take advantage of this program. Further research is warranted. There is a limited number of studies on the use of nurse-led telephone care programs and even less data
942
Pimentel et al.
Vol. 49 No. 5 May 2015
Table 1 Characteristics of Inpatients and Outpatients Who Used the SCCTP Total Variable Age (median, interquartile range) Gender Race
Cancer type
Marital status
Education level CAGE
Level
Female Male White Black Hispanic Asian American Indian Gastrointestinal Thoracic Breast Head and neck Gynecologic Genitourinary Sarcoma Lymphoma/myeloma Leukemia Brain and spine Endocrine Melanoma and skin Married Single Divorced Widowed Separated High school graduate College education No high school Negative Positive
Inpatient
Outpatient
Users a
N
%
N
%
N
%
59
51e68
58
50e67
61
51e67
0.137
204 170 263 49 35 14 11 72 69 53 32 32 30 22 18 16 10 9 4 224 61 44 35 7 87 159 24 276 73
55 45 71 13 9 4 3 20 19 14 9 9 8 6 5 4 3 2 1 60 16 12 9 2 32 57 9 79 21
12 7 15 1 1 2 0 2 0 2 1 5 3 0 0 1 1 2 0 13 2 4 0 0 4 9 0 16 2
63 37 79 5 5 11 0 12 0 12 6 29 18 0 0 6 6 12 0 68 11 21 0 0 31 70 0 89 11
48 48 76 9 6 3 1 18 27 10 14 7 1 8 2 2 1 1 2 59 13 10 13 1 28 48 5 67 28
50 50 80 9 6 3 1 19 29 11 15 8 1 9 2 2 1 1 2 61 14 10 14 1 35 59 6 71 29
0.326
P-value
0.657
Journal of Pain and Symptom Management 939
Brief Report
The Frequency and Factors Associated With the Use of a Dedicated Supportive Care Center Telephone Triaging Program in Patients With Advanced Cancer at a Comprehensive Cancer Center Lindsey E. Pimentel, BSN, RN, CHPN, Sriram Yennurajalingam, MD, Gary Chisholm, MS, Tonya Edwards, MS, RN, CCRP, Maria Guerra-Sanchez, BSN, RN, CCRP, Maxine De La Cruz, MD, Kimberson Tanco, MD, Marieberta Vidal, MD, and Eduardo Bruera, MD Department of Palliative Care and Rehabilitation Medicine (L.E.P., S.Y., T.E., M.G.-S., M.D., K.T., M.V., E.B.) and Department of Biostatistics (G.C.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
Abstract Context. There is limited literature on characteristics of telephone triage programs and the nature of interventions in palliative care. Objectives. Our aim was to determine frequency and type of care provided by a Supportive Care Center Telephone Triaging Program (SCCTP) in advanced cancer patients (ACPs). Methods. Electronic medical records were reviewed of 400 consecutive ACPs referred to palliative care at a comprehensive cancer center and given access to the SCCTP: 200 from the outpatient (OP) supportive care center and 200 from inpatient (IP) palliative care given access after discharge. We reviewed call frequency, type, reason, and outcomes including pain and other symptoms (Edmonton Symptom Assessment Scale and Memorial Delirium Assessment Scale [MDAS]) associated with utilization of the SCCTP. Results. A total of 375 patients were evaluable. One hundred fifteen of 400 patients (29%) used the SCCTP: 96 OPs (83%) used the SCCTP vs. only 19 IPs (17%) (P < 0.001). The most common reasons for calls were pain (24%), pain medication refills (24%), and counseling (12%). For 115 phone calls, 43% (145 of 340) of recommendations were regarding care at home and 56% were regarding opioids. Patients who used the SCCTP had worse pain (P ¼ 0.006), fatigue (P ¼ 0.045), depression (P ¼ 0.041), and well-being (P ¼ 0.015) and better MDAS scores (P ¼ 0.014) compared with nonusers. OPs had a higher prevalence of symptom distress (P ¼ 0.013), depression (P < 0.001), anxiety (P < 0.01), and insomnia scores (P ¼ 0.001); MDAS scores were significantly higher in IPs (P < 0.001). Conclusion. In this study, we found that overall utilization of the SCCTP by ACPs referred to palliative care was relatively low at 28.7%. The use of the SCCTP was particularly poor among the IPs on discharge. Patients who used SCCTP had worse pain, fatigue, depression, and well-being scores and better delirium scores. J Pain Symptom Manage 2015;49:939e944. Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved. Key Words Outpatient palliative care, nurse telephone triage, phone care, supportive care, symptom control
Introduction Palliative care patients experience severe physical and psychosocial symptoms.1,2 These symptoms significantly impact the quality of life of patients and Ms. Pimentel and Dr. Yennurajalingam contributed equally to this work. Address correspondence to: Eduardo Bruera, MD, Department of Palliative Care and Rehabilitation Medicine, Unit 1414, The University of Texas M. D. Anderson Cancer Center, Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
caregivers.3,4 Although most patients receive palliative care in an inpatient (IP) setting, of late a growing portion of patients have been receiving care as outpatients (OPs).5 This is partially a result of longer
1515 Holcombe Boulevard, Houston, TX 77030, USA. E-mail: [email protected] Accepted for publication: October 22, 2014.
0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2014.10.020
940
Pimentel et al.
Vol. 49 No. 5 May 2015
survival seen in patients with advanced cancer and also may result from early referral.6e9 However, many palliative care patients often receive less than two follow-up visits,10,11 perhaps because of worsening symptoms, deteriorating health status, and/or logistical reasons that make adherence to OP supportive care center follow-up visits more difficult. Therefore, because of the increased symptom burden in the advanced cancer patient population, ongoing symptom management for patients receiving palliative care is vital.7,11 Previous studies have suggested that nurse-led telephone triage to improve access to care between physician visits and early symptom management are crucial to providing care to all patients, particularly those with advanced cancer.12,13 However, there is limited literature on the characteristics of telephone triage programs and the nature of interventions.14e17 At The University of Texas M. D. Anderson Cancer Center, palliative care and symptom control is offered in both the IP and OP settings. Patients are referred for management of uncontrolled physical symptoms (pain, fatigue, nausea and vomiting, loss of appetite, and sleep), emotional distress (anxiety, depression, and coping), and to assist with transitioning from curative to palliative care.11,18 The purpose of this study was to describe the frequency and type of telephone calls made by patients and their caregivers to our OP Supportive Care Center Telephone Triaging Program (SCCTP) and the various nursing interventions made during these telephone interactions. We also examined the effect of the SCCTP on pain control and on Edmonton Symptom Assessment Scale (ESAS) symptoms and counseling needs in patients seen by the palliative care service as IPs compared with OP consultations. We hypothesized that OP consultations would use the SCCTP more than IP consultations; patients with high ESAS symptom scores would have increased use, which would lead to decreased symptom distress.
excluded. In total, of the 400 eligible patients, 375 patients were evaluable (n ¼ 200 OP, n ¼ 175 IP). Twenty-five IPs were not evaluable as they expired before discharge from the hospital.
Methods
CAGE Questionnaire. The CAGE Questionnaire is a simple four-item screening survey for alcoholism. CAGE ‘‘positive’’ patients have a higher risk of chemical coping22e24 and require more intense interdisciplinary care.
In this retrospective study, we examined 200 consecutive IPs seen as consultations by the palliative care mobile team (IP) and 200 consecutive OPs seen at the supportive care center (OP) for six months beginning March 12, 2012. Consults were followed for six months from initial contact with palliative care to assess the number of patients who used the SCCTP and the number of calls made by these patients. Information regarding telephone calls from telephone records was systematically collected by OP clinic nurses assigned to telephone triaging each day in the supportive care center. Patients who had previously been seen by the palliative care team were
Process of SCCTP At initial consultation, patients and families receiving palliative care at the OP and IP were educated about the availability of the SCCTP weekdays during clinic hours. Patients and their families were encouraged to call the SCCTP for any issues or concerns regarding palliative care needs on discharge. This was reinforced by providing a visiting card that had instructions including telephone numbers to call the SCCTP. The SCCTP was provided at the OP by a total of five palliative care-trained nurses. All these nurses were highly experienced supportive care nurses who worked daily with palliative care faculty and were very familiar with the administration of the assessment of tools, including the ESAS and the Memorial Delirium Assessment Scale (MDAS), management of medications, and counseling. However, no specific cross-validation was conducted as this study was based on practical clinical care.
Standardized Palliative Care Assessments Edmonton Symptom Assessment Scale. Our team previously designed the ESAS to determine the severity of 10 symptoms commonly experienced by cancer patients during the previous 24 hours; these symptoms are pain, fatigue, nausea, depression, anxiety, drowsiness, dyspnea, anorexia, insomnia, and feelings of well-being.19 The severity of each symptom is rated on a numerical scale of 0e10 (0 ¼ no symptom and 10 ¼ worst possible severity). The ESAS is both valid and reliable in the assessment of the intensity of symptoms in cancer patients.19,20 The ESAS Symptom Distress Score is the sum of ESAS pain, dyspnea, appetite, nausea, fatigue, drowsiness, anxiety, depression, and well-being scores.21
Memorial Delirium Assessment Scale. The MDAS is a structured, 10-item, 0e3 clinician-rated scale (possible range 0e30) designed to quantify the severity of delirium in medically ill patients. This tool was originally tested in a heterogeneous population of cancer and noncancer patients. The MDAS has been used and validated for screening and diagnosis of delirium in cancer patients.25
Vol. 49 No. 5 May 2015
Use of a Dedicated Supportive Care Center Phone Triaging Program
Other Data. The following data were collected: number of calls made by each patient receiving palliative care, reason for the call, and recommendations provided by the SCCTP phone nurse. Telephone calls received were grouped into two categories: interventional and logistical. Interventional needs included management of cancer-related symptoms, such as pain, fatigue, nausea/vomiting, anxiety/depression, appetite, constipation, shortness of breath, sleep, confusion/delirium, and counseling needs. Counseling needs were further categorized into family issues, anxiety/depression, disease state/ progression, hospice information/education, and medication education. Logistical needs addressed over the telephone included medication refills, scheduling, rehabilitation/home health orders, prior authorizations, and interdisciplinary issues/coordinating care. The study also evaluated the nature of each patient call and the necessary nursing interventions made during the telephone interaction. We received institutional review board approval for the conduct of this study.
Statistical Considerations All demographics and outcomes, including frequency and type of interventional calls, were described for both the IP and OP populations using descriptive statistics and graphs, and comparisons were performed using t-tests and Chi-squared tests. To obtain an adequate power, we anticipated 136 (34%) of the 400 patients to be callers and 264 to be noncallers. We used a two-sample t-test to compare the callers and noncallers when alpha ¼ 0.05, so as to achieve 80% power to detect an effect size as small as 0.3 for ESAS pain. Comparison of SCCTP utilization between the two populations (IP and OP) was performed with Poisson regression using time in study (until death, lost to follow-up, or end of study) as an offset. A Poisson regression of call counts on the patient population (200 IPs and 200 OPs) was used so as to obtain a 94% power at a 0.05 significance level to detect a response rate ratio of at least 1.4.
Results A total of 375 patients were evaluable. One hundred fifteen of the 400 patients used the SCCTP. Of the 115 users, 96 (83%) were from OP vs. 19 (17%) from IP (P < 0.001). Fifty-seven percent (65 of 115) of users made more than one call and 89% (58 of 65) were from the OP. Sixty-nine of 115 calls were for interventional needs and 86% (60 of 69) were from the OP group. Forty-five of 115 calls were for logistical needs. We found no significant difference in the patient characteristics of those patients who used the SCCTP vs.
941
those who did not (Table 1). The median age of the patient population was 59 years, 55% were females, and 71% were whites. The most prevalent cancer diagnoses were gastrointestinal (20%) and thoracic (19%). Reasons for utilization of the SCCTP were classified into 14 categories (Fig. 1). The most common reasons for calls were for pain and pain medication refills (each 24%). The second most common reason for calling was for counseling needs (12%). For the 115 telephone calls, a total of 340 recommendations were made (Table 2); 43% (145 of 340) were regarding care at home and 55.6% of these recommendations were regarding management of opioids. There was no significant difference in patient characteristics between frequent (more than one call) and nonfrequent (one call) callers; however, when comparing frequency of calls among patients who used the SCCTP, a higher pain score rating was noted in patients with more than one call. Patients who used SCCTP had better MDAS scores (P ¼ 0.014), and worse pain (P ¼ 0.006), fatigue (P ¼ 0.045), depression (P ¼ 0.041), and feeling of well-being (P ¼ 0.015) scores compared with nonusers. OPs had a significantly higher prevalence of CAGE positivity (28% OPs vs. 11% IPs, P < 0.001), symptom distress (P ¼ 0.013), depression (P < 0.001), anxiety (P < 0.01), and sleep (P ¼ 0.001); MDAS scores were significantly higher in the IPs (P < 0.001).
Discussion In this study, we describe the characteristics of a nurse telephone triage program (SCCTP) in an OP supportive care clinic aimed to complement the interdisciplinary care provided at our clinic by our trained palliative care team so as to improve the quality of life in patients with advanced cancer. We found that the overall use of the SCCTP was relatively low at 28.7%, despite the fact that most patients with advanced cancer were having severe symptom distress and were followed up by supportive care. The use of the SCCTP was particularly poor among the IPs seen in consultation by the Palliative Care Mobile Team. There are a number of possible explanations for this, including shorter length of follow-up, higher frequency of delirium, and perhaps less familiarity of IPs compared with OPs with the OP supportive care center, the site from where SCCTP calls are made (Table 1).26,27 Our results suggest that much more education, such as brochure, a short film, or reminders, are necessary especially among the IPs who are discharged and their caregivers so as to encourage them to take advantage of this program. Further research is warranted. There is a limited number of studies on the use of nurse-led telephone care programs and even less data
942
Pimentel et al.
Vol. 49 No. 5 May 2015
Table 1 Characteristics of Inpatients and Outpatients Who Used the SCCTP Total Variable Age (median, interquartile range) Gender Race
Cancer type
Marital status
Education level CAGE
Level
Female Male White Black Hispanic Asian American Indian Gastrointestinal Thoracic Breast Head and neck Gynecologic Genitourinary Sarcoma Lymphoma/myeloma Leukemia Brain and spine Endocrine Melanoma and skin Married Single Divorced Widowed Separated High school graduate College education No high school Negative Positive
Inpatient
Outpatient
Users a
N
%
N
%
N
%
59
51e68
58
50e67
61
51e67
0.137
204 170 263 49 35 14 11 72 69 53 32 32 30 22 18 16 10 9 4 224 61 44 35 7 87 159 24 276 73
55 45 71 13 9 4 3 20 19 14 9 9 8 6 5 4 3 2 1 60 16 12 9 2 32 57 9 79 21
12 7 15 1 1 2 0 2 0 2 1 5 3 0 0 1 1 2 0 13 2 4 0 0 4 9 0 16 2
63 37 79 5 5 11 0 12 0 12 6 29 18 0 0 6 6 12 0 68 11 21 0 0 31 70 0 89 11
48 48 76 9 6 3 1 18 27 10 14 7 1 8 2 2 1 1 2 59 13 10 13 1 28 48 5 67 28
50 50 80 9 6 3 1 19 29 11 15 8 1 9 2 2 1 1 2 61 14 10 14 1 35 59 6 71 29
0.326
P-value
0.657
