Agreement between HADS classifications and single-item screening questions for anxiety and depression: a cross-sectional survey of cancer patients.

BACKGROUND: We assessed agreement between reported anxiety and depression levels of cancer patients using (i) single self-report items and (ii) the Hospital Anxiety and Depression Scale (HADS). We also explored whether anxiety and depression assessment by (i) single self-report items or (ii) the HADS was most strongly associated with a preference to be offered professional assistance. The proportion of patients indicating that they would accept (or were currently using) professional support if they were experiencing anxiety or depression was also examined. PATIENTS AND METHODS: A consecutive sample of cancer patients undergoing radiotherapy at four metropolitan public hospitals in Australia completed a touch screen computer survey. A consecutive subsample of patients attending three of these treatment centres answered additional questions about psychological support preferences. RESULTS: Of 304 respondents, 54% [95% confidence interval (CI) 48% to 60%] perceived that they were currently experiencing mild to severe anxiety and depression. 22% (95% CI 18% to 27%) indicated a preference to be offered professional help. There was moderate agreement between the HADS and single-item responses for categorisation of anxiety and depression. Patient-perceived mild to severe anxiety and depression levels appeared to be the best measure for identifying those with a preference to be offered professional assistance. Of a subsample of 193 respondents, 89% (95% CI 84% to 93%) indicated that if they were experiencing anxiety or depression, they would accept (or were currently using) professional support. CONCLUSIONS: Single-item screening in a cancer care setting may not adequately capture clinical anxiety and depression. However, single-items assessing patients' perceived levels of anxiety and depression are useful indicators of whether patients want to be offered, and are likely to accept, psychosocial care.

Psychological distress in cancer patients undergoing radiation therapy treatment.

PURPOSE: The objective of this study was to examine the likely presence of, and factors associated with, anxiety, depression and overall psychological distress in cancer outpatients undergoing radiation therapy treatment in Sydney, Australia. METHODS: A touchscreen computer survey was conducted in four radiation therapy treatment centre waiting rooms. Patients waiting to receive treatment completed the survey which included questions about demographic and disease characteristics, survey acceptability and the Hospital Anxiety and Depression Scale (HADS). RESULTS: A total of 454 patients (70 %) completed the touchscreen computer survey. The likely presence of anxiety (HADS-A ≥11), depression (HADS-D ≥11) and overall psychological distress (HADS-T ≥15) was 15, 5.7 and 22 %, respectively. Cancer type was found to be associated with each HADS screening category. The majority of patients reported high survey acceptability and willingness to complete similar touchscreen computer surveys in the treatment centre waiting room on additional occasions. CONCLUSIONS: As radiotherapy patients frequently attend the radiation oncology department, routine screening and intervention for elevated levels of psychological distress in this setting appears to be feasible. High survey completion rates and high patient-rated acceptability support this approach to screening. The likely presence of psychological distress is reported for this sample; however, the selection of HADS threshold scores is likely to have influenced the reported rates. Further research is needed to identify how cancer type impacts on likely caseness across the different HADS classifications examined.

Cancer patients' willingness to answer survey questions about life expectancy.

PURPOSE: This study aimed to determine the proportion and characteristics of radiation oncology outpatients who were willing to answer questions about their life expectancy. METHODS: A cross-sectional patient self-report survey was conducted using touch screen computers in Australian radiation oncology treatment centers. The primary outcome was the respondent's willingness to complete a survey subsection about life expectancy. Demographic and disease characteristics were also collected, and level of anxiety and depression was assessed using the Hospital Anxiety and Depression Scale. RESULTS: Of the 469 oncology outpatients who completed the survey, 327 (70 %; 95 % CI, 65 %, 74 %) indicated that they were willing to answer questions about life expectancy. Being female (p < 0.001), older (p < 0.05), born in Asia (p < 0.05), and being diagnosed with cancer types other than breast and prostate cancer (p < 0.01) were associated with lower odds of answering life expectancy questions. CONCLUSIONS: The opportunity to opt-out of survey questions about sensitive issues such as life expectancy is a feasible method for accessing important information about patient preferences while minimizing burden. Further research may be needed to improve acceptability of life expectancy research to some patient groups.

Current state of medical-advice-seeking behaviour for symptoms of colorectal cancer: determinants of failure and delay in medical consultation.

AIM: There are few data on the factors associated with healthcare-seeking behaviour for symptoms of colorectal cancer. This study describes the determinants of failure and delay in seeking medical advice for rectal bleeding and change in bowel habit. METHOD: In total, 1592 persons (56-88 years) were randomly selected from the Hunter Community Study and mailed a questionnaire. RESULTS: In all, 18% (60/332) of respondents experiencing rectal bleeding and 20% (39/195) reporting change in bowel habit had never consulted a doctor. The rate of delay (>1 month) for each symptom was 18% and 37%. The reasons for delay included the assumption that the symptoms were not serious or that they were benign. Triggers for seeking medical advice varied. Healthcare-seeking behaviour for rectal bleeding had not significantly improved compared with a previous community-based study. CONCLUSION: The seriousness of symptoms, importance of early detection and prompt medical consultation must be articulated in health messages to at-risk persons.

Patient or treatment centre? Where are efforts invested to improve cancer patients' psychosocial outcomes?

The psychosocial outcomes of cancer patients may be influenced by individual-level, social and treatment centre predictors. This paper aimed to examine the extent to which individual, social and treatment centre variables have been examined as predictors or targets of intervention for psychosocial outcomes of cancer patients. Medline was searched to find studies in which the psychological outcomes of cancer patient were primary variables. Papers published in English between 1999 and 2009 that reported primary data relevant to psychosocial outcomes for cancer patients were included, with 20% randomly selected for further coding. Descriptive studies were coded for inclusion of individual, social or treatment centre variables. Intervention studies were coded to determine if the unit of intervention was the individual patient, social unit or treatment centre. After random sampling, 412 publications meeting the inclusion criteria were identified, 169 were descriptive and 243 interventions. Of the descriptive papers 95.0% included individual predictors, and 5.0% social predictors. None of the descriptive papers examined treatment centre variables as predictors of psychosocial outcomes. Similarly, none of the interventions evaluated the effectiveness of treatment centre interventions for improving psychosocial outcomes. Potential reasons for the overwhelming dominance of individual predictors and individual-focused interventions in psychosocial literature are discussed.

The validity and reliability of an interactive computer tobacco and alcohol use survey in general practice.

BACKGROUND: Uncertainty regarding the accuracy of the computer as a data collection or patient screening tool persists. Previous research evaluating the validity of computer health surveys have tended to compare those responses to that of paper survey or clinical interview (as the gold standard). This approach is limited as it assumes that the paper version of the self-report survey is valid and an appropriate gold standard. OBJECTIVES: First, to compare the accuracy of computer and paper methods of assessing self-reported smoking and alcohol use in general practice with biochemical measures as gold standard. Second, to compare the test re-test reliability of computer administration, paper administration and mixed methods of assessing self-reported smoking status and alcohol use in general practice. METHODS: A randomised cross-over design was used. Consenting patients were randomly assigned to one of four groups; Group 1. C-C : completing a computer survey at the time of that consultation (Time 1) and a computer survey 4-7 days later (Time 2); Group 2. C-P: completing a computer survey at Time 1 and a paper survey at Time 2; Group 3. P-C: completing a paper survey at Time 1 and a computer survey at Time 2; and Group 4. P-P: completing a paper survey at Time 1 and 2. At Time 1 all participants also completed biochemical measures to validate self-reported smoking status (expired air carbon monoxide breath test) and alcohol consumption (ethyl alcohol urine assay). RESULTS: Of the 618 who were eligible, 575 (93%) consented to completing the Time 1 surveys. Of these, 71% (N=411) completed Time 2 surveys. Compared to CO, the computer smoking self-report survey demonstrated 91% sensitivity, 94% specificity, 75% positive predictive value (PPV) and 98% negative predictive value (NPV). The equivalent paper survey demonstrated 86% sensitivity, 95% specificity, 80% PPV, and 96% NPV. Compared to urine assay, the computer alcohol use self-report survey demonstrated 92% sensitivity, 50% specificity, 10% PPV and 99% NPV. The equivalent paper survey demonstrated 75% sensitivity, 57% specificity, 6% PPV, and 98% NPV. Level of agreement of smoking self-reports at Time 1 and Time 2 revealed kappa coefficients ranging from 0.95 to 0.98 in each group and hazardous alcohol use self-reports at Time 1 and Time 2 revealed kappa coefficients ranging from 0.90 to 0.96 in each group. CONCLUSION: The collection of self-reported health risk information is equally accurate and reliable using computer interface in the general practice setting as traditional paper survey. Computer survey appears highly reliable and accurate for the measurement of smoking status. Further research is needed to confirm the adequacy of the quantity/frequency measure in detecting those who drink alcohol. Interactive computer administered health surveys offer a number of advantages to researchers and clinicians and further research is warranted.

Are we there yet? The state of the evidence base for guidelines on breaking bad news to cancer patients.

The way clinicians break bad news to cancer patients has been retrospectively associated with poor psychosocial outcomes for patients. Education and practice in breaking bad news may be ineffective for improving patients' well-being unless it is informed by a sound evidence base. In the health field, research efforts are expected to advance evidence over time to inform evidence-based practice. Key characteristics of an advancing evidence base are a predominance of new data, and rigorous intervention studies which prospectively demonstrate improved outcomes. This review aimed to examine the progress of the evidence base in breaking bad news to cancer patients. Manual and computer-based searches (Medline and PsycINFO) were performed to identify publications on the topic of breaking bad news to cancer patients published between January 1995 and March 2009. Relevant publications were coded in terms of whether they provided new data, examined psychosocial outcomes for patients or tested intervention strategies and whether intervention studies met criteria for design rigour. Of the 245 relevant publications, 55.5% provided new data and 16.7% were intervention studies. Much of the intervention effort was directed towards improving provider skills rather than patient outcomes (9.8% of studies). Less than 2% of publications were rigorous intervention studies which addressed psychosocial outcomes for patients. Rigorous intervention studies which evaluate strategies for improving psychosocial outcomes in relation to breaking bad news to cancer patients are needed. Current practice and training regarding breaking bad news cannot be regarded as evidence-based until further research is completed.

The Needs Assessment for Advanced Cancer Patients (NA-ACP): a measure of the perceived needs of patients with advanced, incurable cancer. a study of validity, reliability and acceptability.

AIMS: To describe the psychometric evaluation of a measure designed to assess the perceived needs of patients with advanced, incurable cancer. METHOD: A questionnaire known as the Needs Assessment for Advanced Cancer Patients (NA-ACP) was developed based on a review of available literature and professional opinion. A sample of 246 patients (consent rate = 59%) completed the NA-ACP, 28 patients completed the acceptability questions, while 41 completed a retest copy of the NA-ACP. The construct validity of the questionnaire was examined via principal components analysis, while reliability was evaluated in terms of the internal consistency of domains and test-retest scores. RESULTS: The principal components analysis revealed seven domains assessing patients' psychological/emotional, medical information/communication, social, symptom, daily living, spiritual and financial needs. The test-retest reliability estimates were within accepted levels, as were all but one of the internal consistency scores. The NA-ACP was highly acceptable for this patient group. CONCLUSION: The NA-ACP is one of the first multi-dimensional instruments specifically designed to assess the needs of patients with advanced, incurable cancer. The present study provides evidence of the NA-ACP's validity, reliability, and acceptability. The NA-ACP has potential applications both as a research tool and within clinical settings.

A cost-effective approach to the development of printed materials: a randomized controlled trial of three strategies.

Printed materials have been a primary mode of communication in public health education. Three major approaches to the development of these materials--the application of characteristics identified in the literature, behavioral strategies and marketing strategies--have major implications for both the effectiveness and cost of materials. However, little attention has been directed towards the cost-effectiveness of such approaches. In the present study, three pamphlets were developed using successive addition of each approach: first literature characteristics only ('C' pamphlet), then behavioral strategies ('C + B' pamphlet) and then marketing strategies ('C + B + M' pamphlet). Each pamphlet encouraged women to join a Pap Test Reminder Service (PTRS). Each pamphlet was mailed to a randomly selected sample of 2700 women aged 50-69 years. Registrations with the PTRS were monitored and 420 women in each pamphlet group were surveyed by telephone. It was reported that the 'C + B' and 'C + B + M' pamphlets were significantly more effective than the 'C' pamphlet. The 'C + B' pamphlet was the most cost-effective of the three pamphlets. There were no significant differences between any of the pamphlet groups on acceptability, knowledge or attitudes. It was suggested that the inclusion of behavioral strategies is likely to be a cost-effective approach to the development of printed health education materials.

Print material content and design: is it relevant to effectiveness?

Printed materials are widely used in cancer education. There are a considerable number of guidelines in the literature on the content and design characteristics of print materials. However, there is little outcome-based evidence about whether materials containing these characteristics are more effective under real-world conditions. Six pamphlets were designed such that two had most of these characteristics, one had content characteristics only, one had design characteristics only and two had few of the characteristics. The pamphlets encouraged women aged 50-69 years to join a Pap Test Reminder Service (PTRS). The pamphlets were mailed to a randomly selected sample of 7668 women. Registrations with the PTRS were monitored. Receipt, readership, acceptability, knowledge and attitudes were assessed by telephone interview. There were no significant differences between the pamphlet groups in registrations with the PTRS, receipt, readership, acceptability, knowledge or attitudes. It was concluded that the inclusion of content and design characteristics does not result in more effective print materials.

Trialling a new way to learn clinical skills: systematic clinical appraisal and learning.

AIM: To describe and evaluate the effectiveness of a new method of teaching clinical skills designed to increase students' active and self-directed learning as well as tutor feedback. METHODS: A total of 22 consenting Year 4 medical students undertaking general practice and general surgery clinical experience were involved in a pre- and post-test research design. In the initial period of the study, students were taught clinical skills in a traditional manner. In the second phase a clinical teaching strategy called systematic clinical appraisal and learning (SCAL) was utilised. This learning strategy involved active and self-directed learning, holistic care and immediate feedback. Students independently saw a patient and were asked to make judgements about the patient's potential diagnosis, tests required, management, psychosocial needs, preventive health requirements, and any ethical problems. These judgements were then compared with those of the clinical supervisor, who saw the same patient independently. Students recorded details for each consultation. Comparisons were made of the two study periods to examine whether the use of SCAL increased the number of students' independent judgements, perceived student learning, tutor feedback and self-directed learning. RESULTS: During the SCAL learning period, students reported making a greater number of statistically significant independent judgements, and receiving significantly increased tutor feedback in both general practice and general surgery. The number of learning goals set by students was not found to differ between the two periods in surgery but significantly increased in general practice in the SCAL period. Students' perceptions of their learning significantly increased in the SCAL period in surgery but not in general practice. During the traditional learning period in both settings, there was limited student decision-making about most aspects of care, but particularly those relating to prevention, psychosocial issues and ethics. CONCLUSIONS: The SCAL approach appears to offer some advantages over traditional clinical skills teaching. It appears to encourage active and independent decision-making, and to increase tutor feedback. Further exploration of the approach appears warranted.

Preventive and other interactional skills of general practitioners, surgeons, and physicians: perceived competence and endorsement of postgraduate training.

BACKGROUND: Perceived competencies and support for formal postgraduate training across a range of preventive and other interactional skills were examined in three medical groups. METHODS: All eligible final year students and recent graduates of the three major Australian medical colleges (n = 767) were mailed a questionnaire examining communication skills in four domains: preventive, educational, therapeutic, and general. RESULTS: Overall consent rate was 45%. For most items, at least one-third of each group reported low competence. On preventive items, low competence ratings ranged from 5 to 39% in general practice, 38 to 67% in surgery, and 33 to 51% in the speciality physician group. Significant intergroup differences occurred on eight competence items. Agreement with training on preventive topics ranged from 80 to 91% in general practice, 48 to 69% in surgery, and 72 to 82% in the specialty physician group. On all 11 training items where significant differences occurred, the general practice group reported the highest level and the surgeon group the lowest level of endorsement for formal training and assessment. CONCLUSIONS: Substantial proportions in the general practice, surgery, and the physician specialty report lack of competence in common interactional skills. There were high levels of support for formal training in preventive and other interactional skills. The strong endorsement supports the development of effective, tailored interactional skills training programs.

Perceived needs of women diagnosed with breast cancer: rural versus urban location.

OBJECTIVE: To assess the prevalence and predictors of perceived unmet needs among women diagnosed with breast cancer, with a particular focus on the impact of location (rural/urban). METHOD: A random sample of women in NSW diagnosed with breast cancer was surveyed during 1995-96. The Breast Cancer Patients' Needs Questionnaire (BR-CPNQ) explores patients' perceived needs across five domains: psychological, health information, physical/daily living, patient care/support and interpersonal communication. Items assessing breast cancer specific needs and access to services and resources were included. Of 235 eligible rural women, 134 (57%) consented to participate and 129 (55%) returned completed surveys. Of 196 eligible urban women, 102 (52%) consented to participate and 100 (51%) returned completed surveys. RESULTS: For 12 of the 52 items, at least one-third of the sample reported ever having a moderate/high need for help. Of the 15 highest moderate or high unmet needs, 10 related to health information and three to psychological needs. There were few differences in the prevalence of needs reported by rural and urban women. Only in the physical/daily living domain were rural women more likely than urban women to report some need for help (OR = 2.59, 95% CI 1.21-5.52). CONCLUSIONS: Unmet needs, particularly in the information and psycho-social domains, are reported by both rural and urban women with breast cancer, with sub-groups experiencing different types of needs. IMPLICATIONS: There is a need to develop and trial targeted and innovative strategies to meet the health information and psychological needs of women with breast cancer, and the physical/daily living needs of rural women diagnosed with breast cancer.

Australian oncologists' self-reported knowledge and attitudes about non-traditional therapies used by cancer patients.

OBJECTIVE: To assess Australian radiation and medical oncologists' self-reported knowledge about and attitudes towards a range of non-traditional therapies used by people with cancer. DESIGN: Postal survey during May and June 1997 of all 265 radiation and medical oncologists practising in Australia. PARTICIPANTS: 161 oncologists returned surveys (61% response rate). MAIN OUTCOME MEASURES: Oncologists' own level of knowledge, and, for each known therapy, their perceptions of its likely harm or benefit in patients being treated curatively and palliatively, and of the prevalence of use among their patients. RESULTS: Oncologists reported knowing most about acupuncture, antioxidant therapy and meditation and least about cellular therapy, magnetotherapy and psychic surgery. The therapies most likely to be considered helpful were meditation, acupuncture and hypnotherapy. Those most likely to be considered harmful were coffee enemas, psychic surgery, Iscador therapy and diet therapies. Perceptions of patients' use of most therapies varied widely, with herbal therapies, antioxidant therapy and meditation considered the most commonly used. CONCLUSIONS: These results indicate self-identified gaps in oncologists' knowledge about non-traditional therapies their patients may use; they suggest a need to consider including education about these therapies in oncologists' training.

Collecting cancer risk factor data from hospital outpatients: use of touch-screen computers.

The aim of this study was to assess the prevalence of selected cancer risk factor data from hospital outpatients and the proportion of "at risk" patients who would like help from hospital staff to reduce risk factors. A touch-screen computer collected data from outpatients in Newcastle, NSW, Australia. Eight hundred and nineteen outpatients completed the computerized interview. Of these, 35% were smokers, of whom 25% said that they would like help to stop smoking; 47% were overweight, with 48% indicating that they wanted assistance; 17% consumed harmful levels of alcohol, with 2% wanting help; 30% of eligible women were overdue for a Pap test, of whom 75% said that they wanted a referral to be screened, and 25% were overdue for a mammogram, of whom 83% said that they would like a referral for an examination. Touch-screen computerized health risk assessments are practical for collecting and monitoring valid cancer risk factor data for hospital outpatients.

Randomized controlled trial of a computer strategy to increase general practitioner preventive care.

BACKGROUND: Previous interventions targeting primary care practitioners with the aim of increasing preventive care delivery have demonstrated limited effectiveness. The primary aim of this study was to assess the effectiveness of a computerized continuing medical education program to increase rates of three screening behaviors (cholesterol, blood pressure, and cervical screening) and to identify three risk behaviors (smoking, alcohol consumption, benzodiazepine use) in general practice. METHODS: Nineteen general practitioners were randomly allocated to intervention or control conditions. Those given the intervention received a computerized feedback system. The intervention was delivered using a touch-screen computer located in the surgery waiting area. The preventive behaviors of interest were patient smoking, alcohol use, benzodiazepine use, and blood pressure, cholesterol and cervical screening using the Papanicolou test. Differences in performance by group in each of the outcomes was measured at baseline and 3-month follow-up. Logistic regression analyses with generalized estimating equations were conducted as the main analyses. RESULT: At 3-month follow-up, statistically significant differences were evident in the following outcome measures: accurate classification of benzodiazepine users (z = 2.8540, P < 0.05); accurate classification of non-benzodiazepine users (z = 2.7339, P < 0.05); accurate classification of hazardous or harmful alcohol drinkers (z = 2.3079, P < 0.02); blood pressure screening (z = 3.4136, P < 0.001); and cholesterol screening (z = 6.6313, P < 0.001). CONCLUSION: A computerized system of performance-specific feedback was effective at increasing some preventive care services in general practice.

The physical and psycho-social experiences of patients attending an outpatient medical oncology department: a cross-sectional study.

The aim of this study was to assess the prevalence and predictors of physical symptoms, anxiety, depression and perceived needs among patients receiving treatment at an outpatient medical oncology department using a cross-sectional survey. It was carried out at the outpatient clinic of an academic medical oncology department, which sees around 150-180 outpatients each week; 201 patients were selected. These patients answered questions to assess their levels of anxiety and depression (Hospital Anxiety and Depression Scale), perceived needs (Cancer Needs Questionnaire) and the frequency and severity of 15 physical symptoms. Fatigue, nausea, appetite loss and vomiting were the most commonly experienced and most debilitating physical symptoms. Approximately 25% of participants had borderline or clinical levels of anxiety and depression. Although relatively low levels of perceived needs were reported, physical and psychological needs were the most common. Levels of each outcome measure tended to be predictive of each other. Medical oncology outpatients experience a wide range of physical and psycho-social problems which appear, to some extent, interrelated.

Is there consensus between breast cancer patients and providers on guidelines for breaking bad news?

Eighty-four breast cancer patients, 64 oncologists, and 140 oncology nurses rated the importance of 15 general principles and 12 recommended steps to guide clinicians in breaking bad news to patients. At least 70% of the three samples rated 7 of the 15 principles and 6 of the 12 steps as essential. All three groups agreed that patients have a legal and moral right to accurate and reliable information and that patients should be given the diagnosis and prognosis honestly and in simple language, though not bluntly. The groups differed on the relative importance of other items, with less variation about the steps than about the principles. Patients' perceptions of the importance of various guideline steps and principles are probably most important, given that patients receive the troubling news and that research indicates that how the news is delivered is associated with important patient outcomes. Recommendations for further research are discussed.

Factors relating to cervical screening in New South Wales, Australia.

The aims of this paper were to describe the geographical variation in Pap smear screening rates, standardised for age and adjusted for rates of hysterectomies and to assess the sociodemographic and health care factors associated with the variation. The data used in the study were the percentage of women who had had Pap smears between the years 1990 and 1992 based on the records of the Australian Health Insurance Commission (HIC). The best predictors of screening extracted from the model were the Index of Economic Resources and the proportion of women within each region who were born in non-English speaking countries.

The accuracy of self-reported health behaviors and risk factors relating to cancer and cardiovascular disease in the general population: a critical review.

OBJECTIVE: To critically review the literature concerning the accuracy of self-reported health behaviors and risk factors relating to cancer and cardiovascular disease among the general population. METHOD: A literature search was conducted on three major health research databases: MEDLINE, HealthPLAN, and PsychLit. The bibliographies of located articles were also checked for additional relevant references. Studies meeting the following five inclusion criteria were included in the review: They were investigating the accuracy of self-report among the general population, as opposed to among clinical populations. They employed an adequate and appropriate gold standard. At least 70% of respondents consented to validation, where validation imposed minimal demands on the respondent; and 60% consent to validation was considered acceptable where validation imposed a greater burden. They had a sample size capable of estimating sensitivity and specificity rates with 95% confidence intervals of width +/-10%. The time lag between collection of the self-report and validation data for physical measures did not exceed one month. RESULTS: Twenty-four of 66 identified studies met all the inclusion criteria described above. In the vast majority, self-report data consistently underestimated the proportion of individuals considered "at-risk." Similarly, community prevalences of risk factors were considerably higher according to gold standard data sources than they were according to self-report data. CONCLUSIONS: This review casts serious doubts on the wisdom of relying exclusively on self-reported health information. It suggests that caution should be exercised both when trying to identify at-risk individuals and when estimating the prevalence of risk factors among the general population. The review also suggests a number of ways in which the accuracy of individuals' self-reported health information can be maximized.