Management of cancer patients' symptoms always has been a challenge for providers, especially among racial/ethnic minoritized (REM) populations that often face health disparities that might negatively impact their health outcomes.

THE PROBLEM

Hence, over the years many researchers have evaluated whether electronic tools can help facilitate early recognition of symptoms.

These studies, however, were:

• Mostly implemented in populations that are mostly non-Hispanic white.
• Seldom involved allied health professionals (such as pharmacists) as a resource for symptom management with electronic patient-reported outcomes (ePRO) results.
• Rarely integrated multilingual tools particularly important among REM.

"Early recognition of health issues by pharmacists often is impeded by patients' limited health literacy or poor communication due to language barriers, issues that are highly prevalent among REM," said Alexandre Chan, chair and professor of clinical pharmacy practice at UC Irvine.

PROPOSAL

UC Irvine decided on an intervention building on the scientific framework backed by the National Institute on Minority Health and Health Disparities (NIMHD), which advocates for a multi-domain and multilevel approach to address health disparity.

"Improving early recognition of health issues among REM also may facilitate timely interventions," Chan explained. "Our results show the use of a multi-language ePRO for symptom management, spearheaded by oncology pharmacists, has the potential to address various health disparity issues faced by REM patients.

"And with REM patients being more likely to report certain symptoms – such as pain, nausea and vomiting – our results highlight the use of an ePRO can recognize these symptoms early, reducing health disparities in symptom severity."

MEETING THE CHALLENGE

Adult patients ages 18 years or older newly diagnosed with cancer and receiving intravenous anticancer treatment at the UCI Health Chao Family Comprehensive Cancer Center in Orange were evaluable for inclusion in the study.

Eligible patients were screened through the pharmacy schedule by oncology pharmacists within the electronic health record. The multilevel intervention incorporates ePRO measures to assist oncology pharmacists with symptom management in patients undergoing anticancer treatment. There were three components for the intervention.

"First, screening of symptoms using ePRO," Chan said. "Standardized ePRO assessments were administered through REDCap using computer adaptive tests (CAT). Patients were provided a dedicated iPad prior to or during their infusion and completed their assessments at their infusion chair. The ePRO comprised the Patient-Reported Outcomes Measurement Information System (PROMIS) measures developed by the National Institutes of Health.

"Our ePRO measured seven health domains: nausea and vomiting, physical impairment, anxiety, depression, fatigue, cognitive impairment, and pain interference," he continued. "All domains were administered as CAT, except nausea and vomiting. Measures were chosen to holistically assess toxicities of treatment and physical, mental and social health.

Patients' sociodemographic characteristics, responses to individual PROMIS items, and metrics of PROMIS utilization were also captured.

"Both English and Spanish versions were available," Chan noted. "When a specific language – for example, Vietnamese or Korean – was unavailable, we engaged medical interpreters through video remote technology. After a patient completed the ePRO, raw scores were transformed to degrees of severity (normal, mild, moderate and severe) based on normative thresholds in real time."

The second component is symptom management provided by trained oncology pharmacists.

"An oncology pharmacist immediately reviewed the results from symptom screening and delivered personalized symptom management and treatment counseling to the patient, with content that aligns with current requirements provided by the ASCO QOPI certification program standards," he said.

"Participating pharmacists attended an in-person training session to understand the workflow and to review existing care pathways," he added. "In addition, pharmacists could communicate and document treatment decisions, including ordering prescriptions, with other members of the oncology care team via the EHR."

And the third component is study wrap-up and patients' follow-up. After each visit, patients were asked regarding their satisfaction and acceptability toward the program. Satisfaction was assessed using a single item: "How satisfied are you with the counseling provided by your pharmacist?" on a 5-point Likert scale (very dissatisfied to very satisfied) as adapted from similar studies.

"Acceptability to the length of the ePRO and education session were similarly assessed," Chan explained. "Finally, based on the pharmacist's assessment of patients' symptomatology, participants would either be discharged from the study based on mutual agreement or followed-up at a subsequent visit. This allowed the pharmacist to provide reassessment of patients' symptoms, additional interventions, and/or counseling as necessary.

"By facilitating symptom reporting and intervention, reducing language barriers, and improving communication, our intervention shows potential in addressing health disparity issues at various levels, for example, individual and interpersonal," he continued. "Importantly, our racial/ethnic distribution paralleled the demographic characteristics of the county where the study took place, and patients across racial/ethnic groups expressed willingness to continue with the intervention through multiple visits at a comparable rate."

RESULTS

By implementing an intervention that involves an electronic-patient reported outcome tool coupled with digital analytics, racial/ethnic minorities (Hispanic/Latinx and Asian patients) receiving chemotherapy treatment at Chao Family Comprehensive Cancer Center (a majority minority cancer center) unveiled two times higher likelihood in reporting pain as well as two times higher likelihood in reporting nausea and vomiting compared with non-Hispanic whites.

These findings are likely to be observed in other settings where REM patients diagnosed with cancer are being treated, Chan said.

"Additionally, we also have observed that Hispanic/Latinx patients are two times more likely to use urgent care compared with non-Hispanic white patients," he observed. "This also holds true among other ethnic patients – they are at four times more likely to use urgent care compared with non-Hispanic white patients.

"Using the intervention, the oncology pharmacists also were able to personalize the care of our patients," he continued. "With 90% of the patients expressing satisfaction, our ePRO-driven intervention, led by oncology pharmacists, facilitated symptom assessment and management."

ADVICE FOR OTHERS

Healthcare provider organizations should consider how their tool (if they are developing one) can personalize care if they are dealing with a similar problem, Chan advised.

"Besides integrating into electronic health records, they also need to think about whether they are able to engage pharmacists and providers on the ground to provide timely and immediate personalized symptom management," he concluded. "Additionally, it is important to engage with providers to ensure the organization understands the need of providers."

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