Appropriate Distress Screening and Follow-up Leads to Fewer ER Visits and Hospitalizations in Patients With Cancer

Key Points

  • Adherence to screening protocols led to 18% fewer emergency department visits and 19% fewer hospitalizations in the 2-month period following the screening.
  • Of the 55 centers studied—53 in the United States and 2 in Canada—electronic health records for more than 8,400 patients were examined. Among those reports, 62% of patients received the mandated distress screening and follow-up—the highest rates of which were reported by community cancer programs. Among National Cancer Institute–designated cancer centers, less than half adhered to the protocol.
  • Moreover, regardless of care setting, adherence rates for adolescent and young adult patients (aged 15–39 years) were significantly lower (58%) when compared with other age populations. Researchers identified that the highest adherence rates (70%) were among black/African American patients, while the lowest adherence rates (45%) were found in patients of American Indian/Alaska Native/Native Hawaiian/Pacific Islander descent.

Following a cancer diagnosis, all patients experience some level of distress—regardless of disease stage. When severe and left untreated, distress can have a significant impact on health outcomes, lead to greater mortality and morbidity, affect immune function, and result in higher health-care expenditures through more frequent use of medical services, such as emergency department visits. To combat these issues, the Commission on Cancer (CoC) put into place mandates for routine distress screening at cancer centers.

To uncover the correlation between cancer screening adherence and use of medical services at community and academic cancer centers, researchers at the University of Michigan Comprehensive Cancer Center, led by Brad Zebrack, PhD, MSW, MPH, reviewed electronic health record (EHR) data from 55 cancer centers in the United States and Canada. The results showed that adherence to screening protocols led to 18% fewer emergency department visits and 19% fewer hospitalizations in the 2-month period following the screening.

The study was published by Zebrack et al in the Journal of the National Comprehensive Cancer Network.

Reduced Anxiety and Improved Outcomes

According to Dr. Zebrack, utilization of distress screening protocols, such as the National Comprehensive Cancer Network® (NCCN®) Distress Thermometer, have the ability uncover incapacitating conditions that, if left untreated, could have an incredibly negative impact on patient outcomes.

“Appropriate screening and identification of distress would flag a referral to a social worker, whose clinical assessment would uncover the cause of the patient’s distress and lead to clinical engagement and delivery of an appropriate, evidence-based intervention, complementary to clinical treatment,” said Dr. Zebrack.

To illustrate this impact, the researchers use the example of a screening that uncovers a spouse’s anxiety related to the responsibility of maintaining the patient’s central line at home. In this instance, the authors explain, appropriate response would preempt improper home care, reduce risk of infection, and prevent an emergency department visit and hospitalization.

In many cases, coexisting psychosocial conditions inhibit adherence to therapy, and helping ensure that patients have access to appropriate support breaks down barriers to necessary clinical care and, essentially, better outcomes.

“Just as we do not expect blood pressure screening alone to reduce symptoms of cardiovascular disease, we should not expect distress screening alone to improve outcomes,” said Dr. Zebrack. “There must also be an appropriate clinical response when risk conditions are detected.”

Challenges to Utilization

In 2015, the CoC established accreditation standards for patient-centered care that included a requirement for distress screening for all patients with cancer, as well as appropriate clinical response when warranted.

The University of Michigan study is the first to examine adherence among nonexperimental distress screening protocols. Of the 55 centers studied—53 in the United States and 2 in Canada—EHRs for more than 8,400 patients were examined. Among those reports, 62% of patients received the mandated distress screening and follow-up—the highest rates of which were reported by community cancer programs. Among National Cancer Institute–designated cancer centers, less than half adhered to the protocol.

“Particularly concerning is the finding that documentation of psychosocial screening in one of every three cases in this sample is lacking. The absence of these clinical data can compromise the ability of oncology care providers to know whether patients are receiving the psychosocial care and support they need,” said Dr. Zebrack.

Moreover, regardless of care setting, adherence rates for adolescent and young adult patients (aged 15–39 years) were significantly lower (58%) when compared with other age populations. Researchers identified that the highest adherence rates (70%) were among black/African American patients, while the lowest adherence rates (45%) were found in patients of American Indian/Alaska Native/Native Hawaiian/Pacific Islander descent.

The efficient use of scarce medical resources and the delivery of cost-effective care depends upon getting the right treatments to the right patients at the right times. Distress management protocols are critical for identifying and responding to the needs of patients. When left unchecked, unmet patient needs for psychosocial support contribute to poor patient outcomes and unnecessary use of costly medical services.

Among the cancer centers studied, 84% utilized the NCCN Distress Thermometer and Symptom Checklist—or a modified version thereof. This checklist, derived from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Distress Management, is similar to the pain scale used in various areas of medicine. The distress thermometer allows patients to self-identify their stress level from zero to 10, with 10 being an extreme level of distress. Under the guidelines, patients reporting above a “4” should be referred to supportive care that will best serve their needs. 

The corresponding problem list allows patients to self-identify sources of distress, including practical problems, family problems, emotional problems, spiritual/religious problems, and physical problems.

A patient version of this tool is available free-of-charge at NCCN.org/patients.

“In patients with cancer, distress encompasses far more than anxiety about treatment and prognosis. Encouraging patients to identify and express the sources of distress in their lives will ultimately improve their psychosocial and physical well-being. My hope is that one day, all oncologists will post the NCCN Distress Thermometer in their examination rooms, just as primary care physicians have the eye chart,” said Jimmie Holland, MD, Memorial Sloan Kettering Cancer Center, Founding Chair of the NCCN Guidelines Panel for Distress Management. “Discussion of distress should be a routine part of the patient visit.… I hope these findings will help uncover barriers to appropriate care so that patients will receive the care they need when they need it.”

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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