Prof Phyllis Butow, University of Sydney and Sydney Catalyst

1. 1

2. Implementing psychosocial care
into routine practice:
Making it easy
into routine practice: Making it easy
Prof Phyllis Butow
School of Psychology &
Chair, Psycho-Oncology Co-operative
Research Group (PoCoG)
2

3. 3
Prevalence of distress
Mehnert A et al. JCO 2014; 32: 3540-3551
• Prevalence of distress in cancer patients is HIGH
• Recent definitive study in Germany of in- and out-patients
• Stratified proportional sampling - appropriate representation
of all tumour types
• 4020 patients (68% response rate)
• Patients scoring above 9 on PHQ interviewed with CIDI-O

4. 4-week prevalence of mental disorder
Disorder Prevalence (%) 95% CI (%)
Mental disorder 32 29 - 34
Anxiety 12 10 - 13
Mood disorder 7 6 -8
Adjustment disorder 11 10 -12
4
Mehnert A et al. JCO 2014; 32: 3540-3551

5. Efficacy of interventions
› We know interventions are effective
› Recent meta-analysis: 198 studies - 22,238 patients
› Significant small-to-medium effects for individual and group
psychotherapy and psycho-education
- Larger effects if high distress patients recruited
› Effects sustained, in part, in the medium (< 6 months) and
long term (> 6 months)
5
Faller H et al. JCO 2013; 31(6):782-93

6. Guidelines in psychosocial care
6

7. Screening and management
 Screening patients with cancer for anxiety and depression
is widely recommended internationally
 Early detection and treatment:
 Reduces patient suffering and the likelihood of
developing a major mood disorder
 Improves quality of life
 Reduces health service utilisation
7
• Howell etal (2010), Canadian Association of Psychosocial Oncology: Toronto,
• NCCN, Clinical Practice Guidelines in Oncology. Distress Management Version 2.
• Andersen (2014) Screening, Assessment, and Care of Anxiety and Depressive Symptoms
in Adults With Cancer: ASCO Guideline Adaptation.
• Howell et al (2011) Current Oncology,

8. What happens in practice?
8

9. PoCoG review of screening for distress in Australia
and Internationally
› Review of the literature
› Structured interviews with:
- Key stakeholders from US, Canada, Netherlands, UK and
Australia
- Clinicians, Representatives of Health Departments and
Cancer Councils
Commissioned by Cancer Australia
9

10. Actual practice…
 Screening not routinely conducted in Australia
 Emotional symptoms commonly undetected, severity
under-estimated
 Reasons for not screening?
 Lack of confidence, insufficient training
 Time pressures
 Lack of psychosocial staff and referral guidance - what
to do if someone is identified through screening?
10
Mitchell et al., Psych-oncology , 2008; Absolom etal., Psycho-oncology 2011

11. Screening not the complete answer
11
Distress screening rates in Canada, 2008-2012
Despite this, psychosocial outcomes not improved
Howell D et al, Pall and Supp Care 2014

12. › US and UK data show many oncology health professionals
- Do not value screening data
- Do not respond to it
› Patient referral
remains adhoc
12
Jacobson P et al, 2007
Mitchell A et al, 2012; 2011
Screening data is not used

13. › Synthesis of data from 40 years of screening in the primary
care setting shows that:
› Screening alone does not improve patient outcomes
› A clear clinical pathway, with institutional commitment, is
required
› Mitchell A et al, 2011
13
Screening not the complete answer

14. PoCoG Clinical Pathway
for Anxiety and Depression
 PoCoG developed an evidence-based clinical pathway for
identifying and managing anxiety and depression in cancer patients
 Development guided by:
 existing empirical evidence
 wide stakeholder consultation
 in-depth clinician interviews
 a delphi process with 87 multidisciplinary stakeholders
Shaw J, Price M et al. Supportive Care in Cancer 2015
14

15. PoCoG pathway
› Process of stakeholder involvement designed to
ensure engagement
› Gaining multi-disciplinary perspectives designed to
ensure the pathway is acceptable to all groups
› Pathway designed to provide clear and detailed
guidance
15

16. Methods
 Conducted a two-round, on-line Delphi study
 Round 1: 39 statements across 6 domains
 Scoring:
 Statements rated
 1 (strongly disagree) to 5 (strongly agree)
 Free text comments to justify response
 Consensus defined as 80% or more of respondents rating
the item within two points on the scale
 In round 2, participants re-rated statements that failed to
gain consensus in light of the overall group responses
16

17. Participants
 Participants:
 87 clinically active members of PoCoG from a range of
disciplines:
 Medical and radiation oncologists, nurses,
psychologists, social workers, palliative care
physicians, psychiatrists, GPs and cancer surgeons
 Rural/regional and metropolitan regions across all states
 Range of practice settings
 Public/private
 Tertiary referral centres, regional hospitals
 Outpatient/community services
17

18. Results – key findings
Screening
Broad agreement
 Pathways should be tailored for local implementation based
on local resources as well as patient characteristics
 Screening should be routinely implemented and formalised
 Designated staff member should be responsible
No consensus on specific methods of screening
 Two step process
 Edmonton Symptom Assessment System (ESAS)
 Who is most appropriate to conduct screening
18

19. Results – key findings
Assessment and Referral
Broad agreement
 Further assessment to clarify the nature and severity of
anxiety/depression
 Need to accommodate patient treatment preferences
 Need for patient education to maximise uptake of services
No consensus on:
 Whether screening and subsequent assessment should
be carried out simultaneously by the same staff member
or sequentially
19

20. Results – key findings
Stepped Care Clinical Pathway
Broad agreement
 Stepped care model for managing anxiety/depression is
appropriate
No consensus on:
 Whether practical and spiritual issues should be
included in the pathway
 Inclusion of treatment time frames
20

21. Results-key findings
Monitoring and Care Coordination
Broad agreement
 Responsibility for coordination of care will depend on local
staffing, resources, patient factors and preferences
 Ongoing monitoring and follow up:
 Lower levels of distress: nurses, oncologists and
GPs responsible
 Higher levels: specialised mental health
professionals take on responsibility
No consensus on:
 Who should be responsible for coordination of care for
anxiety/depression
21

22. Conclusions
 Our results confirmed:
 Overall support for the clinical pathway
 Support for routine formal screening of
anxiety/depression in oncology
 Support for stepped-care model of treatment and review
 Need for flexibility in pathway implementation
 Lack of consensus on specific screening methods and
roles for management and co-ordination of care
22

23. The Pathway:
 Is flexible and tailored to each site
 Incorporates screening, referral and management
recommendations
 Provides timing for follow up
 Suggests roles and responsibilities
 Utilises a stepped care model
 5 steps from minimal to severe anxiety/depression
 Patients receive least intensive intervention likely to
be effective
 More intensive interventions reserved for patients
who do not benefit from simpler first line treatments

24. Clinical Pathway
24

25. 25

26. Can we get this clinical pathway
into routine practice?
26

27. Lack of research into “The gap”
› Despite an increase in intervention studies, there is a
serious lack of implementation / dissemination studies
› <6% of studies aim to close gap between evidence and
clinical practice
› Bryant J, Boyes A, Jones K, et al: Examining and addressing evidence-
practice gaps in cancer care: a systematic review. Implement Sci 9:5908-9,
2014
27

28. PARiHS framework
28

29. Barriers analysis
- How can we implement the pathway?
- Qualitative interviews:
- Expert opinion elicited via audio-recorded semi-structured
interviews - 12 multi-disciplinary clinicians
- Transcribed, coded and analysed
- Rankin N, Butow P et al. BMC Health Services Research, 2014

30. Resources
› Lack of time, staff, resources, facilities
› No agreement on screening tools & cut off scores
Responsibility
› Who screens? Assesses? Refers?
› Ethical responsibility of detecting distress
Staff barriers

31. Enabling implementation
Engagement
“…Engagement with psychosocial services and the nursing staff as a
starting point is really important because ... at the end of the day
they’re going to implement it.”
Education and training
“(You) have to … offer training to the oncologists and nursing staff
in terms of basic psycho-education and... have some simple
resources that could be provided to patients.”
31

32. Enabling implementation
Evidence-based, and will make their life easier
“Widespread education that highlights both the importance of
psychosocial assessment, as well as the efficacy of intervention(s)
“... how it reduces clinician time by identifying and intervening with
psychological distress in a timely manner.. and .. prevents
unnecessary admissions and presentations, as well as improving
quality of life and satisfaction with care
“…how this improves the clinical life for the coal-face oncologist. And
how it improves the quality of life of patients and their carers”
32

33. Patient barriers
Patient reluctance
› Stigma of mental health care
› Feel embarrassed they are not coping
› Don’t want to burden cancer care team
› Feel they are not bad enough to warrant care, have enough support
at home
“For a lot of people, it’ll be the first time they’ve ever spoken to
someone about distress, so it’s not a simple step”
“There’s a great resistance with some people... there’s one
gentleman … who is just refusing point blank to see anybody, yet his
wife is telling me that he’s spending most of his time in tears at
home....”
33

34. Patient reluctance
34

35. Enabling intervention
› Patient resources
- Booklets and internet sites that normalise
psychological morbidity and care
› Staff training in making an effective referral
- Role-play, online resources
35

36. System barriers and solutions
Culture of health services
“there needs to be explicit support from the institution that
spending time on these issues is time well spent. That it’s valued
and supported, people are given time to do it, and that it is a
priority...so that everybody’s engaged in this being an important
service initiative…”
Change management
“It needs to be system level intervention where these things are
…integrated, in routine documentation, in IT systems and in quality
review.”
36

37. Enabling implementation
Adoption into health policy at state and local level
“ I think one of the things that might help you, though... the funding
they get for cancer services from the NSW health department ...
there’s key KPIs that they have to meet…
And if something like this was built into the memorandum of
understanding ... it means that... at local district level you’ve got
senior buy in to say ‘this is an expectation of our cancer services”
37

38. CINSW Translational Program Grant
OVERALL AIMS
• Facilitate the integration of the clinical
pathway for anxiety and depression in cancer
patients into routine care
• Develop and evaluate implementation
strategies to promote uptake of pathways in
the Australian health context.

39. Chief Investigators Associate Investigators
› Prof Phyllis Butow
› Prof Gavin Andrews
› Prof Afaf Girgis
› Prof Brian Kelly
› Prof Tom Hack
› A/Prof Josephine Clayton
› Dr Melanie Price
› A/Prof Philip Beale
› Prof Rosalie Viney
› Dr Laura Kirsten
+ Consumer advisory group
› Dr Joanne Shaw
› Dr Haryana Dhillon
› Dr Joseph Coll
› Dr Peter Grimison
› Prof Tim Shaw
› Dr Nicole Rankin
› Dr Michael Murphy
› Dr Jill Newby
› Mr John Stubbs
› Dr Frances Orr
› Dr Toni Lindsay
Wide expertise

40. Clinical partners
› Four Cancer Institute NSW Translational Cancer Research
Centres (TCRCs)
- Sydney Catalyst
- Centre for Oncology Education and Research Translation
- Sydney Vital
- Sydney West
-
- TCRCs are networks of clinical and research teams
- Will encourage buy-in and engagement
- Will champion the work

41. How will we address barriers?
Target Barrier Strategy
Administration /
Leaders
Lack of support • Appoint clinical and administrative
champions
• Involve TCRCs
• CINSW backing
General
Oncology staff
Lack of team
ownership
Involve key staff from all disciplines in
tailoring the pathway to their context
Lack of education
re why and how
Online educational resources with role-play
demos and cases:
• Empathic communication
• How to screen
• How to make a referral
(Especially if patient reluctant)
Available on EVI-Q and at point of contact,
with annual reminders to review
41

42. Educational resources
42
;

43. Target Barrier Strategy
General Oncology staff Lack of time Automated system which:
• Cues patient to complete online
assessment at baseline and follow-up
• Provides graph of scores over time
• Sends email to staff when patient is
over cut-off, for further assessment
• Provides links to referral template
• Emails referral to pre-specified staff
• Is linked to electronic records if possible
(eg MOSAIQ)
Psychosocial staff Lack of time Develop online cognitive-behavioural
therapy to which mild to moderate cases
can be referred
• Keeps staff informed of progress
• Staff cued if further intervention needed
Encourage wider referral options 43
How will we address barriers?

44. Online therapy
44

45. Target Barrier Strategy
Patients • Stigma
• Reluctance to
burden staff
Patient written and online resources:
• Explain anxiety and depression
• Normalise
• Note part of routine care
• Provide a lay version of the pathway
Train staff to screen and refer well
45
How will we address barriers?

46. Research programme
› A cluster randomized controlled trial (RCT) to
evaluate the cost and efficacy of:
- an intensive, tailored implementation strategy
- versus
- a basic implementation strategy
for the anxiety and depression clinical pathway

47. All sites
› Access to all the health professional, patient and
system resources
› On-site briefing session on pathway and systems
› Posters advertising the program
47

48. Intervention sites
› Training and ongoing support of local champions
› Audit and feedback prior to and midway through the
intervention
› Face-to-face education regarding the portal and
online tools which support the pathway
› Facilitated tailoring of the pathway to the local setting
› IT support
› Other strategies to address the specific barriers and
facilitators in each site
48

49. The outcome?
› We hope:
- The clinical pathway will remain in use
- Improved knowledge about implementing health
practice change
- Ultimately, better outcomes for patients
49

50. IN SUMMARY
› If we are to really improve psychosocial outcomes,
we need proven interventions, clinical pathways,
› AND
› Careful attention to implementation
› It is not easy, but it can be done!
50

51. Or we could…
51