An interventional study of Routine Data collection and Feedback of patient-reported outcomes in Pediatric Neoplasm, Quality of Life and Outcome Assessment, sponsored by Dana-Farber Cancer Institute. Completed at 4 sites in United States. Open to participants aged 2 Years to 25 Years. Per ClinicalTrials.gov, last updated 2013-04-29.
Sponsored by Dana-Farber Cancer Institute · Not applicable, Interventional, and Supportive care
Over 50% of children dying from cancer still suffer from symptoms that could be effectively alleviated. The purpose of the Pediatric Quality of Life and Evaluation of Symptoms Technology (PediQUEST) Study was to evaluate whether providing feedback to families and providers about how the child is feeling improved child distress and quality of life (QoL) in children with advanced cancer.
PediQUEST is a computerized survey that asks the child and/or parents how the child has been feeling, i.e. whether the child had any physical or emotional symptoms, as well as how other aspects of life, such as school and friends, are going. After the survey is complete a report that summarizes patient/parent answers is printed. When a child reports moderate to high distress from any symptom an email is automatically sent to the primary providers (oncologist, nurse, and psycho-social clinician as well as the pain and palliative care services) alerting them about the child's distress.
In this study we evaluated whether using PediQUEST and providing printed reports to parents and providers reduced distress and improved quality of life in children with advanced cancer. In addition, we wanted to understand whether it was feasible to carry out a randomized controlled trial in children with advanced cancer. Finally, the data collected, will be used to describe the natural history of symptoms and quality of life as reported by the children.
Children enrolled in the study (or their parents) were asked to complete a PediQUEST survey at most once a week. A random half of the children received the feedback intervention, i.e. patients, parents, and providers received printed reports (and emails if the child was in distress). The other half only completed the PediQUEST surveys and did not receive reports. We analyzed data collected over 20 weeks of follow-up to see whether receiving PediQUEST reports had any effect on child distress and quality of life.
Introduction: Cancer is the leading cause of nonaccidental death in childhood.(Arias et al. 2003) In spite of significant scientific progress, one quarter of children with cancer still do not survive(Greenlee et al. 2000), and over 50% experience substantial suffering that could be alleviated.(Wolfe et al. 2000a) Pediatric palliative care is now an expected standard of care and research in this field has been established as a national priority by the Institute of Medicine (IOM).(Field et al. 2003) Earlier work by our group suggested that when parents and physicians recognized at an early stage that a child had no realistic chance of cure, they were more likely to integrate elements of effective palliation into the child's care. However, this early stage concordance about prognosis was rare.(Wolfe et al. 2000b) Communication and delivery of optimal care in the advanced stages of illness is especially challenging in children.(Shelton 1999) The anticipation of losing a child and physicians' own difficulties(Saunders 1979-80; Hilden et al. 2001) may hinder discussions about poor prognosis and impact on decision-making and integration of palliative care. Thus attention to symptom management and quality of life (QoL) in children with advanced cancer may be limited.
The collection of standardized symptom and QoL data has shown to enhance physician's recognition, knowledge and accuracy in the assessment and palliation of symptoms, and to increase patient-provider discussions about QoL issues and directly improve patient's QoL.(Detmar et al. 2002; Taenzer et al. 2000; Velikova et al. 2004) Whether these findings are applicable to children remains to be established.
One of the obstacles to routine symptom and QoL assessment in children is the need of developmentally adapted(Eiser et al. 2001b; Eiser et al. 2001c; Hain 1997) and parent-proxy tools(Eiser et al. 2001a), making the paper and pencil format extremely impractical. Computerized surveys offered a potential solution. Patient acceptance of such devices has been found to be high.(Buxton et al. 1998; Velikova et al. 2002; Velikova et al. 1999; Velikova et al. 2001) Our current project -the PediQUEST Study- consists of a pilot for a randomized controlled trial (RCT) aimed at assessing the effect of routinely reporting symptom and QoL data. We will use an innovative data collection strategy: a hand-held computer devise, the Pediatric Quality of Life and Evaluation of Symptoms Technology (PediQUEST) that readily administers a user-appropriate survey instrument and generates reports summarizing how the patient feels.
As far as we are aware of, this will be the first RCT conducted in children with advanced cancer to evaluate a palliative care intervention. Given the challenges with doing research in this population, we propose to simultaneously focus on several goals.
Aims: Aim 1: (Feasibility study) Assess the feasibility of conducting a randomized controlled supportive care trial (RCT) in children with advanced cancer. Aim 2: (PediQUEST Evaluation) Preliminarily assess the effect of routinely feeding back QoL and symptom data to families and primary oncologists, and alerting supportive care teams about highly distressing symptoms. Aim 3: (Descriptive study) Prospectively explore determinants of child's suffering and parental-physician discordance regarding prognosis and treatment goals in children with advanced cancer.
Design: Aim 1: Cohort survey study; Aim 2: Pilot prospective RCT; Aim 3: Cohort study embedded in an RCT.
Setting: Three large US pediatric cancer centers. Subjects: 104 children 2-years old and above with advanced cancer and their parents were enrolled between December 2004 and June 2009.
Follow-up: Patients were initially followed up for 9 months or until death whatever occurred first. However, an interim analysis of the first 29 patients showed that 75% were alive at nine months, suggesting the enrollment of a healthier cohort. We therefore changed the follow-up period to 3 months with the option of multiple re-enrollments until the end of data collection (December 2009) or death.
Methods:
Feasibility study: All subjects approached for enrollment were invited to complete a one-time paper and pencil "Consent survey" regardless of their decision about whether to participate. All enrolled subjects were asked to complete a paper and pencil "Participation survey" after completing the study or dropping-out in order to explore determinants of attrition.
PediQUEST Evaluation and Descriptive studies: Symptom and QOL scores were tracked up to once a week. Surveys were embedded in the PediQUEST system and administered through tablet computers.
Participants' recruitment: Eligible children were identified through daily review of clinic roster with clinic staff including nurses, oncologists and/or nurse practitioners and verified with the patient's primary oncologist using a checklist sent over email. If after being introduced to the study and having had the opportunity to ask questions, child and parent(s) were willing to participate, parent(s) were asked to review and sign the informed permission/assent document covering the parent(s) and child's participation. A provider's completion of the eligibility checklist will indicate informed consent of providers.
Study Instruments:
Intervention: Patients were randomly allocated to receive routine feedback about symptoms and QOL. The feedback intervention had two components: (i) PQ-reports: printed reports were made available to providers (inserted in charts before the visit) and families (handed immediately after survey completion at clinic or ward). PQ-reports consisted of bar plots of PedsQL and MSAS symptom scores from current and four prior administrations, a summary highlighting changes since last report, and a list of available resources for symptom control (for families), or generic pain management recommendations (for providers). Training on how to interpret PQ-reports was offered to families at enrollment and on an annual basis to providers; (ii) PQ emails: were automatically generated if PQ-MSAS individual symptom scores were ≥70, or if on two consecutive administrations the patient or parent reported a score of ≥70 for any frequency, severity or distress item, or a PedsQL total score ≤ 40. E-mails were sent to primary providers (oncologist, nurse, and psychosocial clinician), the local palliative care service, and, when pain was reported, the pain service (or equivalent). No instructions were imparted on how to respond to emails. Families and providers of patients in the control arm of the study did not receive feedback reports. The allocation process was embedded in PediQUEST and blinded to investigators until the patient completed the first survey. Because of the nature of the intervention this was an open label study. As a token of our appreciation, small non-monetary incentives were provided to children, parents, and providers.
Outcomes: This study explores the feasibility of conducting an RCT assessing a supportive care intervention in children with advanced cancer (aim 1). It also provides estimates of consent and attrition rates, its determinants, and the burden associated with repeated measurements. In addition, this pilot study will preliminarily assess the impact of feedback on child's distress and quality of life. Main outcomes of this efficacy study (aim 2) are presented below. This pilot study will render sufficient data for accurate sample size calculation for future studies and serve to explore determinants of suffering in children with advanced cancer (aim 3).
Statistical Analysis:
PediQUEST Evaluation (Aim 2): To assess the effect of PediQUEST, the proportion of patients with unrelieved symptoms in each arm will be compared using odds ratios and associated chi-square tests. To assess the progression of reported levels of child's distress and QOL trends, we will run a mixed effects model that assumes a linear trend in the outcome over 20 weeks of follow up for each subject. The model will examine the difference in the average trend over time (slope) between the intervention and control group by including a fixed effect term that represents the interaction of treatment status and time since study entry. Lack of difference between slope coefficients will support the null hypothesis of no effect by the intervention. Single point secondary outcomes will be analyzed by comparing both arms with a t test or Wilcoxon rank-sum test for continuous outcomes and odds ratios and associated chi-square tests for proportions.
Sample Size and Power Calculations A formal sample size estimation was not possible given the lack of data on distribution of scores in an advanced cancer population or their variation over time. For this reason we originally proposed to recruit 120 patients and their parents, a sample size driven by practical rather than statistical considerations that would serve as a basis for future sample size calculations. We estimated that 60 subjects per arm would allow for an adequate balance between arms and likely provide sufficient power to detect large clinical effects for single point measurements.
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Exclusion Criteria:
Routine collection of patient-reported symptom and Quality of life data using PediQUEST surveys
Other: Routine Data collection
Routine collection of QOL and symptom data + feedback
Other: Routine Data collection · Other: Feedback of patient-reported outcomes
Patients assigned to the control arm answered PediQUEST (PQ) surveys at most once a week and at least once a month. PQ-surveys were administered through a tablet computer if patient was at the clinic or ward or over the phone if patient was primarily at home. PQ-survey had 9 age- and respondent- adapted versions. Control arm participants reported their satisfaction with the PediQUEST technology twice 4th and 8th PediQUEST administration. These surveys were embedded in PediQUEST.
Also known as: Control arm
Patients, parents and primary providers received printed reports summarizing patient/parent reported outcomes for last five visits. When child reported moderate-severe distress an email was automatically sent to primary providers (oncologist, nurses and psychosocial clinicians), as well as to the pain and palliative care services.
Also known as: Feedback, Intervention arm
Child Distress - unrelieved symptoms
Child distress-unrelieved symptoms will be assessed through the proportion of patients with unrelieved symptoms (any symptom/s reported as causing moderate to high distress or FPS-R score \>=8 in 2 consecutive PediQUEST evaluations)
Time frame: 20 weeks
Trends of PedsQL Total Scores
Trends of PedsQL total scores over time. PedsQL is a continuous variable (Range: 0-100. 100 highest quality of life).
Time frame: 20 weeks
Trends of MSAS total scores
Trends of MSAS total score over time(MSAS total score is a continuous variable; range: 0-100. 100 worst).
Time frame: 20 weeks
Trends of MSAS physical scores
Trends over time of MSAS physical subscale scores (MSAS physical subscale score is a continuous variable. Range: 0-100. 100 highly symptomatic.)
Time frame: 20 weeks
Trends of MSAS psychological scores
Trends over time of MSAS psychological subscale scores (MSAS psychological subscale scores is a continuous variable. Range: 0-100. 100 highly symptomatic.)
Time frame: 20 weeks
Trends of PedsQL Physical Subscale Scores
Trends of PedsQL physical subscale scores over time. PedsQL physical score is a continuous variable (Range: 0-100. 100 highest quality of life).
Time frame: 20 weeks
Trends of PedsQL Emotional Subscale Scores
Trends of PedsQL emotional subscale scores over time. PedsQL emotional score is a continuous variable (Range: 0-100. 100 highest quality of life).
Time frame: 20 weeks
Parental distress over time
Trends in Kessler-6 scores (general psychological distress scale) over 20 weeks. Continuous variable. Range:0-24 (24 is high distress).
Time frame: 20 weeks
Patterns of care - Referrals to support services
N° of referrals to support services (Psychiatry service, Pastoral Care): continuous variable.
Time frame: 20 weeks
Patterns of care - Chemotherapy during last month of life
Proportion of patients receiving chemotherapy during the last month of life
Time frame: 20 weeks
Patterns of care - Use of hospice/home care
Proportion of patients receiving home care assistance or hospice care
Time frame: 20 weeks
Patterns of care - Time of documentation of prognosis discussions
Time of documentation (N° of days before death) of discussions about prognosis
Time frame: 20 weeks
Patterns of care - Time of documentation of resuscitation status
Time of documentation (N° of days before death) of discussions about resuscitation status
Time frame: 20 weeks
Patterns of care - Ventilatory assistance in last day of life
Proportion of patients who were intubated in the last 24 hrs of life.
Time frame: 20 weeks
Patterns of care - Hospital deaths
Proportion of patients who died at the hospital
Time frame: 20 weeks
Satisfaction with PediQUEST
Satisfaction with the technology and with the feedback system will be assessed twice at the fourth and eight PediQUEST administration. Specifically we will assess consumers'impressions about the technology, easiness of use, relevance. Among those receiving the feedback intervention we also assessed whether reports helped parents understand their children's feelings better, facilitated communication with doctors and overall satisfaction with the technology and feedback. Finally, we also assessed providers satisfaction with feedback reports including their impression about the reports and whether reports affected their behaviors regarding symptom management.
Time frame: At 4th PediQUEST administration
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