UC Irvine’s Electronic Patient-Reported Outcomes Tool Reduces Disparities in Cancer Care

Managing the symptoms of cancer patients has historically been a challenge for healthcare providers, especially among racial/ethnic minority (RME) groups who often face health disparities that can negatively impact their health.

THE PROBLEM

That is why, over the years, many researchers have investigated whether electronic aids can help in early detection of symptoms.

However, these studies were:

• Mainly used in population groups that consist largely of non-Hispanic whites.
• Rarely are allied health professionals (such as pharmacists) involved as a resource for symptom management with electronic patient reported outcomes (ePRO).
• Rarely integrated multilingual resources are especially important in REM education.

“Early identification of health problems by pharmacists is often hampered by patients’ limited health literacy or poor communication due to language barriers, issues that are common in REM patients,” said Alexandre Chan, chair and professor of clinical pharmacy at UC Irvine.

PROPOSAL

UC Irvine decided on an intervention that builds on the scientific framework of the National Institute on Minority Health and Health Disparities (NIMHD), which advocates a multidomain, multilevel approach to addressing health disparities.

“Improving early recognition of health problems in REM patients may also facilitate timely interventions,” Chan explained. “Our results demonstrate that the use of a multilingual ePRO for symptom management, driven by oncology pharmacists, has the potential to address several health disparities faced by REM patients.

“And because REM patients are more likely to report certain symptoms, such as pain, nausea and vomiting, our results highlight that using an ePRO could identify these symptoms early, reducing health disparities in symptom severity.”

TOOK UP THE CHALLENGE

Adult patients 18 years and older who had recently been diagnosed with cancer and were undergoing intravenous cancer treatment at the UCI Health Chao Family Comprehensive Cancer Center in Orange were eligible to participate in the study.

Eligible patients were screened via the pharmacy schedule by oncology pharmacists in the electronic medical record. The multi-level intervention includes ePRO measures to assist oncology pharmacists with symptom management in patients undergoing anticancer treatment. The intervention consisted of three components.

“First, symptom screening using ePRO,” Chan said. “Standardized ePRO assessments were administered via REDCap using computer adaptive testing (CAT). Patients were given a special iPad before or during their infusion and completed their assessments at their infusion chair. The ePRO included 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 disability, anxiety, depression, fatigue, cognitive disability, and pain interference,” he continued. “All domains were administered as CAT, except nausea and vomiting. The measures were chosen to holistically assess treatment toxicity and physical, mental, and social health.

Patients’ sociodemographic characteristics, responses to individual PROMIS items, and statistics on PROMIS use were also recorded.

“Both English and Spanish versions were available,” Chan noted. “When a specific language—for example, Vietnamese or Korean—was not available, we brought in medical interpreters via remote video technology. After a patient completed the ePRO, the raw scores were converted to severity levels (normal, mild, moderate, and severe) based on normative thresholds in real time.”

The second component is symptom management by trained oncology pharmacists.

“An oncology pharmacist immediately reviewed the results of the symptom screening and provided the patient with personalized symptom management and treatment advice, with content aligned with current ASCO QOPI certification program standards requirements,” he said.

“Participating pharmacists completed an in-person training session to understand the workflow and review existing care pathways,” he added. “In addition, pharmacists were able to communicate and document treatment decisions, including prescription ordering, with other members of the oncology care team through the EHR.”

And the third part is the completion of the study and the follow-up of the patients. After each visit, the patients were asked about their satisfaction and acceptance of the program. Satisfaction was assessed using one item: “How satisfied are you with the counseling that your pharmacist provides you?” on a 5-point Likert scale (very dissatisfied to very satisfied), adapted from similar studies.

“The acceptability of the length of the ePRO and the educational session were assessed in the same manner,” Chan explained. “Finally, based on the pharmacist’s assessment of the patients’ symptomatology, participants were either discharged from the study by mutual consent or followed up at a subsequent visit. This allowed the pharmacist to reassess the patients’ symptoms, implement additional interventions, and/or provide counseling as needed.

“By facilitating symptom reporting and intervention, reducing language barriers, and improving communication, our intervention shows potential in addressing health disparities at multiple levels, such as individual and interpersonal,” he continued. “Importantly, our racial/ethnic distribution paralleled the demographic characteristics of the county where the study took place, and patients from all racial/ethnic groups indicated willingness to continue the intervention through multiple visits at a similar rate.”

RESULTS

Implementation of an intervention using an electronic patient reporting tool combined with digital analytics found that racial/ethnic minorities (Hispanic/Latino and Asian patients) receiving chemotherapy at Chao Family Comprehensive Cancer Center (a minority-majority cancer center) reported twice the rate of pain and twice the rate of nausea and vomiting compared to non-Hispanic whites.

According to Chan, these findings are likely to be seen in other settings where REM patients are treated with cancer.

“In addition, we also found that Hispanic/Latinx patients use the emergency department twice as often compared to non-Hispanic white patients,” he noted. “This is also true for other ethnic patients – they use the emergency department four times as often compared to non-Hispanic white patients.

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

ADVICE FOR OTHERS

Chan advises that healthcare providers should consider how their device (if they develop one) can personalize care if they are faced with a similar problem.

“In addition to integrating into electronic health records, they also need to think about whether they can engage pharmacists and providers on site to provide timely and immediate personalized symptom management,” he concluded. “In addition, it’s important to engage with providers to ensure the organization understands the needs of providers.”

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