Clinical Practice Guideline Development, Implementation, and Evaluation in an Oncology Practice
AbstractBackground: Forty percent of adult cancer patients suffer from at least one clinically significant episode of anxiety and/or depression during their illness. When these mental health problems are untreated, patients will adhere less to their treatment regimens and have weakened immune systems thereby leading to more disease- related complications and higher rates of morbidity and mortality. Despite the high rate of comorbid emotional distress in cancer and its negative sequelae, most patients are not receiving appropriate care. Clinical practice guidelines can direct the detection and treatment of mental health problems that can be integrated into the cancer setting. Purpose: The purpose of this quality improvement project was to develop a best-practice guideline to screen, assess and manage patients with depression and cancer and test its feasibility in an out-patient oncology practice. Procedure: A multi-disciplinary consensus group reviewed recent literature and solicited staff opinion to develop a set of eight best practice recommendations adapted from the American Society of Clinical Oncology Guidelines for Depression and Anxiety. Based on these recommendations, a stepped-care model was developed using a multidisciplinary framework and including an algorithm with a clinical pathway to guide treatment and work flow. During a five-week period all new patients were screened at their first appointments with the Patient Health Questionionnre-9, (PHQ-9) a self-administered, nine-item scale to detect presence and severity of depression. Based on their scores, they were offered psychosocial education and, if necessary, referral to community mental health specialists. Descriptive statistics were computed to calculate PHQ-9 scores, frequency of use of tool and success of the stepped care model to direct care. Results: Between the times of data collection, 308 patients were admitted to the clinic. Of these, 240 were successfully screened for depression. One-hundred and eighty-nine of these screenings were reviewed by the patient’s provider. According to the cut-off criteria for mild (5-9), moderate (10-14), and severe (>15) depression, 84 (mild), 16 (moderate) and 9 (severe) patients were identified as positive cases. Over half of the patients (55%) were negative for depression while over a third (35%) reported minimal depression. A small portion of patients had moderate (7%) and severe (3%) depression. Of the 109 positive screens (PHQ-9 score ≥5), in 61 cases, the appropriate hand-off communication to social work occurred. Of the patients successfully triaged to social work, all were provided psychoeducation and moderate and severe cases of depression were also provided with at least one community referral. Adherence to protocol was 78% and was calculated based on: the number of patients successfully screened over the five-week period (240), the number of patient screenings reviewed by the patient provider (189) and the number of patients successfully referred to social work (61). Conclusion: Strategies to increase adherence include improving handoff interdisciplinary communication particularly between the technicians responsible for the screening and the social worker completing the advanced assessment. This could be done by streamlining work flow processes such as assigning one staff member per shift to complete all screenings which would also increase accountability. Clinical guidelines and an algorithm to guide practice should be adapted by all clinical facilities. This project increased ability of providers to identify depression in cancer patients and successfully directed patients to receiving the level of care appropriate to their need.
KeywordPatient Health Questionnaire
Identifier to cite or link to this itemhttp://hdl.handle.net/10713/7770
The following license files are associated with this item: