Identifying and Managing Distress in Patients With Head and Neck Cancers


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A quality improvement initiative at the Norris Cotton Cancer Center in Lebanon, New Hampshire, resulted in biweekly screening rates for psychological distress among patients treated at the head and neck medical oncology clinic increasing from 0% to 74% within a 2-year period. “Distress screening also became an integral component of clinic work flow,” Natalie Riblet, MD, MPH, and colleagues from the Norris Cotton Cancer Center reported in the Journal of the National Comprehensive Cancer Network.

“Furthermore, providers and patients reported that the process improvement produced meaningful changes, in that providers appreciated having a tool to identify high-risk patients and an evidence-based guideline to help inform clinical care. Patients valued the opportunity to discuss this aspect of their health and to know that the treatment plan addressed their mental and physical health needs,” the authors noted.

The importance of identifying patients at risk for psychological distress is recognized in the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology for Distress Management and ASCO’s Quality Oncology Practice Initiative (QOPI) measures, the authors noted. However, few U.S. cancer centers have adopted formalized screening programs for distress.

The process for identifying and managing psychosocial distress at the head and neck cancer medical oncology clinic at Norris Cotton Cancer Center involved a two-component quality improvement intervention: the validated NCCN Distress Thermometer (a visual analog scale allowing patients to rate their perceived level of distress in the last 7 days) and an evidence-based treatment decision algorithm.

Screening processes were improved through “Plan-Do-Study-Act” cycles, the authors explained. “Cause-effect diagramming suggested that lack of a formalized process for distress assessment contributed to missed diagnoses. Providers were also unfamiliar with mental health resources.” Among specific strategies to improve screening were: including visual prompts on clinic notes for providers to incorporate distress screening into routine care, revising provider note templates to ease the burden of documentation, compiling an antidepressant guideline and list of available mental health resources, and developing a patient-centered poster to educate patients about distress and encourage them to take a more active role in their care.

“After implementing process changes, biweekly distress screening rates rose from 0% to 38% between January and July 2011. Furthermore, with additional [Plan-Do-Study-Act] cycles, these rates increased to 74% between October 2011 and April 2012,” the authors reported. The screening rate for newly diagnosed patients using the NCCN Distress Thermometer was 84%, “and this screening rate met previously described benchmarks for best performing cancer centers.”

The investigators identified four “keys to success” in designing a head and neck cancer screening program: (1) characterize and address the unique needs of their patients and providers, (2) incorporate screening into established workflow patterns and electronic medical record, (3) track outcomes and share results with key stakeholders, and (4) involve senior leadership in improvement efforts. ■

Riblet N, et al: J Natl Comp Canc Netw 12:1005–1013, 2014.



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