Veronica Decker

Evidence-Based Practice for Telemental Health

Telemental Health Standards and Guidelines Working Group Co-Chairs: Brian Grady, MD Kathleen Myers, MD, MPH Eve-Lynn Nelson, PhD Writing Committees: Evidence-Based Practice for Telemental Health Norbert Belz, MHSA RHIA, Leslie Bennett, LCSW, Lisa Carnahan, PhD, Veronica Decker, APRN, BC, MBA, Brian Grady, MD, Dwight Holden, MD, Kathleen Myers, MD, MPH, Eve-Lynn Nelson, PhD, Gregg Perry, MD, Lynne S. Rosenthal, PhD, Nancy Rowe, Ryan Spaulding, PhD, Carolyn Turvey, PhD, Debbie Voyles, Robert White, MA, LCPC Practice Guidelines for Videoconferencing-Based Telemental Health Peter Yellowlees, MD, Jay Shore, MD, Lisa Roberts, PhD Contributors: Working Group Members [WG], Consultants [C], Reviewers [R], Telemental Health Special Interest Group Chairs [MH], ATA Standards and Guidelines Committee Member [SG], ATA Staff [S] Nina Antoniotti, RN, MBA, PhD [Chair, SG] Richard S. Bakalar, MD [SG] Norbert Belz, MHSA RHIA [WG] Leslie Bennett, LCSW [WG] Jordana Bernard, MBA [S] Anne Burdick, MD, MPH [Vice Chair, SG] David...

An Intervention to Improve Adherence and Management of Symptoms for Patients Prescribed Oral Chemotherapy Agents: An Exploratory Study

Background: Use of oral chemotherapy agents to treat cancer has increased. Patients are responsible for adhering to complex regimens while managing symptoms from adverse effects of the chemotherapy. Objective: This study examined an intervention to manage symptoms and adherence to oral agents. Methods: A 3-group pilot study determined how an Automated Voice Response (AVR) system alone (n = 40), or the AVR with strategies to manage symptoms and adherence (n = 40), or the AVR with strategies to manage adherence (n = 39) reduced symptom severity and improved adherence. Participants received a Symptom Management Toolkit, completed a baseline interview, and were randomized to receive 8 weekly AVR calls. An exit interview occurred at 10 weeks. Results: Mean age was 59.6 years, with 70% female and 76% white, and 42% were nonadherent, with missed doses increasing with regimen complexity. Symptom severity declined over time in all groups. No difference was found in adherence rates, and higher adherence was related with lower symptom severity across groups. Conclusions: Adherence, a significant clinical problem, can affect efficacy of the cancer treatment. The AVR intervention alone was just as effective as the AVR plus the nurse intervention at promoting adherence and managing symptoms from adverse effects. Implications for Practice: Nurses need to focus on patient education by ensuring patient understanding of oral agent regimen and the need to adhere to the oral agent for efficacious cancer treatment. Nurses can promote the use of medication reminders and self-management of symptoms from adverse effects, to support adherence to the oral agent.

A pilot study of an automated voice response system and nursing intervention to monitor adherence to oral chemotherapy agents.

This study was designed to develop and test a system to monitor adherence with nonhormonal oral chemotherapeutic agents using an automated voice response (AVR) system plus nursing intervention. Participants were patients diagnosed with solid tumor cancers, primarily breast, colon, and lung cancers, who received the Symptom Management Toolkit and participated in an interview for symptom severity, satisfaction, and beliefs about oral agents. Patients received weekly AVR calls, which assessed adherence to oral agents and severity of 15 symptoms. Patients who reported adherence of below 100% of the prescribed oral agents or symptoms of 4 or greater (0-10 scale) for 3 consecutive weeks were called by a nurse for assistance with symptom management and adherence to oral chemotherapy medications. After the 8 weekly AVR calls, patients participated in a follow-up interview and medical record review. Participants were 30 oncology patients who were ambulatory and treated at 2 cancer centers in Midwest United States. The results indicate 23.3% nonadherence rate to oral chemotherapy medications due to symptoms and forgetting to take the medication. An association between symptom management and adherence was found. Symptom severity and beliefs about medications were not significantly different between adherent and nonadherent patients. This pilot study demonstrated the ability to accrue patients for a longitudinal trial and informed intervention design while providing guidance for future interventions and research studies.

Issues Related to Overadherence to Oral Chemotherapy or Targeted Agents

Use of oral chemotherapy or targeted agents is shifting how cancer treatment is administered, moving it from supervised office visits to self-administration at home. This study examines issues related to overadherence to oral agents that were noted during a trial conducted by the authors comparing an automated voice system to strategies to reduce symptom severity and improve adherence. Overadherence to oral agents may be a significant clinical problem, occurring more often in patients with complex dosing regimens, and may lead to increased symptom severity from side effects of treatment. Avoiding overadherence may be important for the reduction or prevention of symptoms and potentially life-threatening toxicity. Nurses need to discuss with their patients the importance of the timing of the administration of their oral oncolytic regimen, as well as to provide prompts to assist in self-administration as prescribed so that overadherence can be avoided.

Ethnicity Disparities of Breast Cancer within an Insured Population

To the Editor: Between 2005 and 2009, Hispanic women had lower breast cancer incidence, but a worse 5-year survival rate, compared to non-Hispanic white women (1). As seen in other cancers, this disparity in outcomes may reflect Hispanic women being diagnosed at an advanced stage due to less access to preventive and follow-up screening (1–3). Such disparities have been explained by nationwide studies based on multiple cancer registries as due to socioeconomic status or cultural differences that may preclude or complicate their access to quality health care (1,2). However, disparities due to other factors may also vary at the facility level. The Florida Hospital System (FHS) consists of eight campuses throughout central Florida and is a major health care provider for the community serving an ethnically diverse population, with Hispanics making up ~22.9% of the population. Over 95% of cases in the Florida Hospital tumor registry are insured patients with one or a combination of Medicaid, Medicare, and various types of commercial insurance. With a data set limited to patients with insurance at diagnosis, the FHS patient population provides a uniquely appropriate patient population to differentiate the cause/ effect of disparities in clinical outcome of breast cancer from other socioeconomic mitigating factors. Hispanic and non-Hispanic white female patients (≥18 years) who were first diagnosed with breast cancer at Florida Hospital between 2001 and 2006 were included (Table 1). Multiple Logistic regression analyses were used to estimate odds ratios (OR) of late to early stage in relation to ethnicity, age, and insurance type. Multiple Cox proportional hazard models and cumulative incidence functions were used to compare death rates between the two ethnicities. Of 1,131 patients studied, Hispanics were found to be over 10 times as likely as non-Hispanic whites to have Medicaid insurance (OR = 10.15, 95% CI: 4.99–20.70). Medicaid patients were more likely to be diagnosed at a late stage than non-Medicaid patients (OR = 4.73; 95% CI: 2.16–10.38; p < 0.001). As age increased, patients were less likely to be diagnosed at a late stage (OR = 0.86; 95% CI: 0.74–0.99; p = 0.038). The death rate was significantly associated with age, insurance type, and stage rather than ethnicity. We found no significant difference in survival based solely on ethnicity.