Practice patterns, experiences, and challenges of German oncology health care staff with smoking cessation in patients with cancer: a cross-sectional survey study.

PURPOSE: Often, cancer patients do not receive education about the negative consequences of smoking on the treatment outcome. To support cancer patients in the process of smoking cessation, it is essential to involve oncology staff. This study aims to learn about the experiences and attitudes from the point of view of oncology staff and, thus, how a smoking intervention should be designed. The study aims to engage all oncology staff due to the unclear responsibility for providing smoking cessation education, support, and motivating cancer patients to quit smoking. METHODS: N = 354 German oncology staff (oncologists, nurses, psycho-oncologists, others) filled out a 5-point Likert scale-based questionnaire regarding practices, potential barriers, and attitudes towards smoking cessation between October 2021 and June 2022. The questionnaire was developed by Derksen et al. (2020), translated and slightly modified for the use of this study. It was distributed to all leading oncology staff in our Cancer Center Network with a request to share with all oncology staff. Flyers were also handed out in all oncology wards and outpatient clinics in the same Cancer Center Network. RESULTS: Most oncology staff ask cancer patients about their current smoking status (curative, M = 2.27; SD = 1.59; palliative, M = 2.90; SD = 1.83), but they rarely treat or refer patients for a smoking cessation intervention (curative, M = 4.78; SD = 1.20; palliative, M = 4.99; SD = 1.06). Smoking behavior of curative cancer patients is addressed more than that of palliative cancer patients (d = - 37). Regression analyses of key dependent variables showed that profession, setting, and the belief that continued smoking affects treatment outcome explained the variance of asking patients if they smoke, advising to stop smoking and lack of time (without profession). CONCLUSION: Involving oncology staff in motivating cancer patients who smoke to quit and referring them to smoking cessation services should take the different attitudes and knowledge of the staff into account to improve treatment that supports tobacco cessation. IMPLICATIONS FOR CANCER SURVIVORS: Cancer patients have special needs when it comes to a cessation program. In the long term, survivors will benefit from tailored smoking cessation education and services provided by oncology staff to help them quit smoking after a cancer diagnosis.

Cognitive Deficits in Executive and Language Functions Predict Postoperative Delirium.

OBJECTIVES: Postoperative delirium (POD) remains the most common complication in older adults, with cognitive impairment being the main risk factor. Patients with mild cognitive impairment, in particular, have much to lose from delirium; despite this, their cognitive impairment might be clinically overlooked. Understanding which cognitive domains are particularly predictive in this regard may improve the sensitivity of preoperative testing and allow for a more targeted application of resource-intensive measures to prevent delirium in the perioperative period. The authors conducted this study with the aim of identifying the most indicative cognitive domains. DESIGN: A secondary analysis of a randomized controlled trial. SETTING: At a single center, the University Medical Centre Hamburg in Hamburg, Germany. PARTICIPANTS: Patients ≥60 years without major neurocognitive disorders (dementia, Mini-Mental State Examination score ≤23) scheduled for cardiovascular surgery. MEASUREMENTS AND MAIN RESULTS: Preoperative neuropsychologic testing and delirium screening were performed twice daily until postoperative day 5. A multiple logistic regression model was applied to determine the predictive ability of test performances for the development of delirium. RESULTS: A total of 541 patients were included in the analysis; the delirium rate was 15.6%. After controlling for confounders, only low performance within the Trail Making Test B/A (odds ratio [OR] = 1.32; 95% CI: 1.05-1.66) and letter fluency (OR = 0.66; 95% CI: 0.45-0.96) predicted a particularly high risk for delirium development. The discriminative ability of the final multiple logistic regression model to predict POD had an area under the curve of 0.786. CONCLUSIONS: Impairment in the cognitive domains of executive function and language skills associated with memory, inhibition, and access speed seem to be particularly associated with the development of delirium after surgery in adults ≥65 years of age without apparent preoperative neurocognitive impairment.

Predictors of Discharge Destination After Stroke.

BACKGROUND: Determining the discharge destination after acute stroke care is important to prevent long-term disabilities and improve cost efficiency. OBJECTIVE: The aim of this study was to investigate where stroke patients are discharged to after acute treatment and to identify personal, social, stroke-related, and clinical predictors of discharge destination. METHODS: The present study included a secondary exploratory analysis of a prospective observational study. Patients with acute ischemic stroke, transient ischemic attack, or intracerebral hemorrhage were recruited consecutively over a 15-month period. A hierarchical multinomial logistic regression was performed to identify predictors of the primary outcome of discharge destination. RESULTS: We included 1026 stroke patients (48.7% female) with a mean age of 73.3 years (standard deviation 12.9 years) in the analysis. Overall, 55% of the patients were discharged home, 33% to a rehabilitation center, 3% to a residential facility, and 8% to another acute care hospital. Predictors that statistically significantly influenced the odds of the discharge destination were age, living situation pre-stroke, living location pre-stroke, stroke type, stroke severity, treatment type, and length of stay. Higher stroke severity was associated with discharge to all four inpatient facilities. CONCLUSIONS: In line with previous research, predictors such as stroke severity and living situation pre-stroke significantly influenced the odds of the discharge destination. In contrast, pre-existing conditions and functional impairment pre-stroke had no significant impact on the primary outcome. This discrepancy could be due to a rather functional study sample before stroke and the use of clinical and patient-reported outcome measures.

Smoking patterns and the intention to quit in German patients with cancer: study protocol for a cross-sectional observational study.

INTRODUCTION: Patients who continue to smoke cigarettes after a cancer diagnosis can experience poorer treatment tolerance and outcomes than those who quit immediately. Identifying risk factors specific to patients with cancer who smoke, as well as their smoking behaviours (eg, frequency of use, types of tobacco products), dependency level and quit intentions, is necessary to better inform patients and encourage quitting smoking after a cancer diagnosis. This study aims to examine the occurrence of smoking in patients with cancer treated at specialised oncology departments and outpatient clinics based within the metropolitan region of Hamburg, Germany, and presents an analysis of their smoking patterns. This understanding is the first step in developing an adequate smoking cessation intervention and shall contribute to a sustainable improvement in the treatment results, long-term survival and quality of life of patients with cancer. METHODS AND ANALYSIS: A questionnaire will be administered to patients with cancer (N=865) aged 18 years and above in the catchment area of Hamburg, Germany. Data acquisition includes sociodemographic, medical and psychosocial data as well as information on current smoking patterns. To identify the associations between smoking patterns and sociodemographic characteristics, disease-related variables, and psychological risk factors, descriptive statistics and multiple logistic as well as multinomial regressions will be performed. ETHICS AND DISSEMINATION: This study was registered at Open Science Framework (https://doi.org/10.17605/OSF.IO/PGBY8). It was approved by the ethics committee of the local psychological Ethic committee at the centre of psychosocial medicine Hamburg, Germany (LPEK) (tracking number: LPEK-0212). The study will be carried out in accordance with the Code of Ethics of the Declaration of Helsinki. The results will be published in peer-reviewed scientific journals.

Higher comorbidity burden is associated with lower self-reported quality of life after stroke.

Introduction: This study assesses the association of comorbidity burden and polypharmacy with self-reported quality of life after stroke. Patients and methods: We performed a post-hoc analysis of a prospective, single-center, observational study of outcome evaluation by patient-reported outcome measures in stroke clinical practice. Consecutive patients with acute ischemic stroke (AIS) were enrolled and self-reported health-related quality of life (HrQoL) was assessed 90 days after acute stroke using the Patient-reported Outcomes Measurement Information System 10-Question Short-Form (PROMIS-10). Comorbidities at baseline were assessed by the Charlson Comorbidity Index (CCI). Polypharmacy was defined as medication intake of ≥5 at baseline. We used linear regression analysis to study the association of CCI, polypharmacy and other clinical covariates with HrQoL after stroke. Results: Of 781 patients (median age 76 years, 48.4% female) enrolled, 30.2% had a CCI Score ≥2, and 31.5% presented with polypharmacy. At follow up, 71 (9.1%) had died. In 409 (52.4%) reached for outcome evaluation, Global Physical Health T-Score was 43.8 ± 10 and Global Mental Health T-Score was 43.5 ± 8.76, indicating lower HrQoL than the average population. A CCI Score ≥2, higher NIHSS Score, female sex, dependency on others for dressing, toileting and mobility before index stroke, atrial fibrillation and hypertension were independent predictors of worse physical and mental health outcomes, while polypharmacy was not. Conclusion: In patients with AIS, high comorbidity burden and polypharmacy are frequent. Comorbidity burden at admission is independently associated with worse self-reported physical and mental health three months after stroke.

Implementability of collecting patient-reported outcome data in stroke unit care - a qualitative study.

BACKGROUND: Patient-reported outcome measures (PROMs) assess patient-relevant effects of medical treatments. We aimed to evaluate the implementation of the International Consortium for Health Outcomes Measurement Standard Set for Stroke (ICHOM-SSS) into routine inpatient care of a stroke unit. METHODS: The ICHOM-SSS was administered in a certified stroke unit during and after inpatient care. Semi-structured interviews with medical staff (n = 5) and patients or their proxies (n = 19) about their experience were audio-recorded and analysed using thematic analyses. Implementation outcomes were chosen in advance and adhered to current standards of implementation science. RESULTS: Patients perceived the ICHOM-SSS to be relevant and feasible. They reported limited understanding of why the assessment was introduced. The overall acceptance of using PROMs was high. While medical staff, too, perceived the assessment to be appropriate and relevant, their appraisal of feasibility, sustainability, and their acceptance of the implementation were low. CONCLUSIONS: For a sustainable implementation of PROMs in clinical practice, IT resources need to be adapted, medical care needs to be reorganized, and additional clinical resources are required. Future research should investigate benefits of the ICHOM-SSS and a simpler, automated implementation in stroke care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03795948 , retrospectively registered on 8 January 2019.

Profiles of patients' self-reported health after acute stroke.

BACKGROUND: We aimed to identify groups of patients with similar health status after stroke, assessed by patient reported outcome measures (PROMs), to improve initial risk stratification. METHODS: In a prospective study, inpatients were recruited during acute stroke treatment. Demographics, history, and cardio-vascular risk factors were assessed at baseline. Self-reported functional status, physical and mental health as well as anxiety and depressive symptoms were assessed 3 and 12 months after stroke and used to identify latent classes. The association of patient characteristics with latent class membership was investigated with multinomial logistic regression. RESULTS: Of the 650 patients included with a mean age of 75 years and 48% female, 70% had ischemic, 6% hemorrhagic strokes, and 24% transient ischemic attacks. Median NIHSS on admission was 2 (IQR:0,5). Values of PROMs remained comparable at 3 and 12 months. A three-class model was developed, differentiating between patients with mildly (75%), moderately (17%), and severely (8%) impaired self-reported health status. Adjusted for univariately significant baseline characteristics, initial NIHSS distinguished mild- from moderate-, and moderate- from severe-class-membership (p < 0.001). Length of inpatient stay (p < 0.001;OR = 1.1), diabetes (p = 0.021;OR = 1.91), and atrial fibrillation (p = 0.004;OR = 2.20) predicted allocation to the moderately vs. mildly affected class. CONCLUSIONS: Grading stroke patients by a standard set of PROMs up to 1 year after stroke allows to distinguish the diverse impact of baseline characteristics on differently affected groups. In addition to initial stroke severity, longer inpatient stay, presence of diabetes and atrial fibrillation correlate with greater impairment of self-reported health in the less affected groups. TRIAL REGISTRATION: http://www.ClinicalTrials.gov ; Unique identifier: NCT03795948 .

Psychometric properties of a patient-reported outcome set in acute stroke patients.

OBJECTIVES: Impairments after stroke may affect multiple domains of health-related quality of life (HRQoL). Patient-reported outcome measures (PROMs) have proven valuable in measuring patients' well-being. We examine the psychometric properties of a standard set of PROMs assessing global health, anxiety, and depression, and functioning in a German health care setting. METHOD: We included inpatients at the Department of Neurology at the University Medical Center Hamburg-Eppendorf, diagnosed with stroke. Following the stroke-specific standard set of the International Consortium for Health Outcome Measurement, we collected demographic and clinical information at baseline, and PROMs for global health (PROMIS-10), three items for self-reported functioning, anxiety, and depression (PHQ-4) at 90 days follow-up. We calculated confirmatory factor analyses to test factorial validity and correlation analyses to test construct validity. We further conducted item and reliability analyses. RESULTS: In a sample of 487 patients (mean age, SD: 71.1, 12.6; 47% female) with mild and moderate symptoms, model fit for the PROMIS-10 was acceptable for the two-factor and single-factor models. Factor loadings ranged from 0.52 to 0.94. The postulated single-factor model for functioning was saturated with zero degrees of freedom. Factor loadings ranged from 0.90 to 0.96. For the PHQ-4, the two-factor model showed excellent model fit. Factor loadings ranged from 0.78 to 0.87. Internal consistency was acceptable to good. Construct validity was generally confirmed. CONCLUSIONS: The PROMIS-10 is a valid and reliable instrument to measure HRQoL among German stroke patients. While the PHQ-4 was confirmed as a screening measure for mental disorders, further research is needed on items assessing self-reported functioning. Results are limited to patients showing minimal functional deficits.

Physical and mental health in HIV-infected patients with virological success and long-term exposure to antiretroviral therapy.

In people living with HIV (PLWH), a decade-long antiretroviral therapy (ART) poses new challenges regarding physical and mental health. The aim of this cross-sectional study is to investigate the health-related quality of life (HRQOL) in adult HIV-infected patients with viral suppression and an ART exposure for at least 5 years in three German HIV centers. Patients were evaluated by the ACTG Augmented Symptoms Distress Module (ASDM) and the SF-12 Health Survey. Among 894 patients, symptom-related distress was highly prevalent. The most common symptoms were fatigue, insomnia, sadness and depression, sexual dysfunction, and changes in body appearance. In the multivariate analysis, ART duration, age and depression were significantly associated with a higher overall symptom summary score. Self-reported mean SF-12 scores were lower for mental health and younger patients compared to the standard random sample of a healthy German population. Depression and occupational status were significantly related to a lower physical component summary score, by contrast older age was associated with higher scores in the mental component summary, implying more favorable mental health status. In this large group of PLWH, the degree of symptom-related distress was high. Mental and physical health should be considered an integral part of ongoing HIV care.

Improvement of perioperative care of the elderly patient (PeriAge): protocol of a controlled interventional feasibility study.

INTRODUCTION: Geriatric patients have a pronounced risk to suffer from postoperative complications. While effective risk-specific perioperative measures have been studied in controlled experimental settings, they are rarely found in routine healthcare. This study aims (1) to implement a multicomponent preoperative and intraoperative intervention, and investigate its feasibility, and (2) exploratorily assess the effectiveness of the intervention in routine healthcare. METHODS AND ANALYSIS: Feasibility and exploratory effectiveness of the intervention will be investigated in a monocentric, prospective, non-randomised, controlled trial. The intervention includes systematic information for patients and family about measures to prevent postoperative complications; preoperative screening for frailty, malnutrition, strength and mobility with nutrient supplementation and physical exercise (prehabilitation) as needed. Further components focus on potentially inadequate medication, patient blood-management and carbohydrate loading prior to surgery, retainment of orientation aids in the operating room and a geriatric anaesthesia concept. Data will successively be collected from control, implementation and intervention groups. Patients aged 65+ with impending surgery will be included. A sample size of 240, n=80 per group, is planned. Assessments will take place at inclusion and 2, 30 and 180 days after surgery. Mixed-methods analyses will be performed. Exploratory effectiveness will be assessed using mixed segmented regressions. The primary endpoint is functional status. Secondary endpoints include cognitive performance, health-related quality of life, length of inpatient stay and occurrence of postoperative complications. Feasibility will be assessed through semi-structured interviews with staff and patients and quantitative analyses of the data quality, focussing on practicability, acceptance, adoption and fidelity to protocol. ETHICS AND DISSEMINATION: The study will be carried out in accordance with the Helsinki Declaration and to principles of good scientific practice. The Ethics Committee of the Medical Association Hamburg, Germany, approved the protocol (study ID: PV5596). Results will be disseminated in scientific journals and healthcare conferences. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT03325413.

Outcome evaluation by patient reported outcome measures in stroke clinical practice (EPOS) protocol for a prospective observation and implementation study.

INTRODUCTION: The impact of stroke-related impairment on activities of daily living may vary between patients, and can only be estimated by applying patient-reported outcome measures. The International Consortium for Health Outcome Measurement has developed a standard set of instruments that combine clinical and longitudinal patient-reported outcome measures for stroke. The present study was designed (1) to implement and evaluate the feasibility of the use of it as a consistent outcome measure in clinical routine at the stroke center of a German university hospital, (2) to characterize impairment in everyday life caused by stroke, and (3) to identify predictive factors associated with patient-relevant outcomes. METHODS: We plan to enroll 1040 consecutive patients with the diagnosis of acute ischemic stroke, transient ischemic attack, or intracerebral hemorrhage in a prospective observational study. Demographics, cardiovascular risk factors, and living situation are assessed at inpatient surveillance. At 90 days and 12 months after inclusion, follow-up assessments take place including the Patient-reported Outcomes Measurement Information System 10-Question Short Form (PROMIS-10), the Patient- Health Questionnaire-4, and the simplified modified Ranking Scale questionnaire. The acceptance and feasibility (1) will be assessed by a process evaluation through qualitative semi-structured interviews with clinical staff and patients and quantitative analyses of the data quality evaluating practicability, acceptance, adoption, and fidelity to protocol. The primary outcome of objective 2 and 3 is health-related quality of life measured with the PROMIS-10. Additional outcomes are depressive and anxiety symptoms and patient participation in their social roles. Patient-reported outcomes will be assessed in their longitudinal course using (generalized) mixed regressions. Exploratory descriptive and inference statistical analyses will be used to find patterns of patient characteristics and predictive factors of the outcome domains. PERSPECTIVE: The results will describe and further establish the evaluation of stroke patients of a stroke center by standardized PROMs in everyday life. TRIAL REGISTRATION: The trial is registered at ClinicalTrials.gov (NCT03795948). Approval of the local ethics committee (Ethik-Kommission der Ärztekammer Hamburg) has been obtained.