Screening Alone Is Not Enough: The Importance of Appropriate Triage, Referral, and Evidence-Based Treatment of Distress and Common Problems

Abstract

See accompanying article on page 3631Hollingworth et al 1 are to be commended on their careful execution of this study, including an adequately powered sample size, long follow-up period, and the addition of a thorough economic analysis, which is rarely undertaken in the context of psychosocial interventions. This is particularly important in countries with nationalized health care systems such as the United Kingdom, where changes to practice may often be widely implemented without knowledge of the economic implications. In general, psychosocial interventions tend to pay for themselves many times over in subsequent cost-offsets, 2,3 but this needs to be examined carefully on a case-by-case basis before widespread implementation. In this study, implementation of the screening-for-distress program did not result in lower subsequent health care costs. However, despite several strengths, major study design limitations may explain this result, temper interpretations, and inform further clinical implementation of screening for distress programs. Though the authors have called their program a needs assessment in their report, the background literature, tools chosen, and the analysis and outcome measures seem to have been designed to test a distress-screening intervention, and my editorial considers the shortcomings of the study in such light.For distress screening programs to be efficacious, three things have to happen: broad identification of patients potentially in need (using the screening tool), further assessment and triage to appropriate services (by adequately trained staff), and evidence-based treatment of symptoms and problems (also by adequately trained professionals across a variety of disciplines). Specific evidence-based treatments would depend on the problems identified but could include cognitive-behavioral therapy, stress reduction, fatigue management, exercise, resource counseling, or family counseling. While step one was followed in this trial, step two did not happen, and therefore step three didn't even have a chance.The major design limitations around these omissions include confounding of treatment and control arms; lack of training of implementation staff; and, most seriously, not following evidence-based triage and referral algorithms (ie, screening and assessment applied as if it were treatment). The staff who delivered the intervention was the same in both the treatment arm, which implemented the screening tool, and the control arm, which did not. Hence, there is concern of a contamination or spill-over effect into the usual care control arm from the distress-screening training for the intervention, which would theoretically increase sensitivity toward psychosocial issues. This would be more of an issue in a trial that showed benefit in both arms. In this case, the result was no benefit in either arm, which mitigates concerns about contamination but raises questions of the adequacy of staff training.Indeed, the training received by the nurses and radiographers was one four-hour seminar "includi...

Feasibility of a quality improvement strategy integrating psychosocial care into 28 medical cancer centers (HuCare project)

“…However, as recently suggested by Carlson regarding screening for distress [38], our study also required centers to define clearly the actions to adopt to ensure that psychosocial problem detection would be followed by appropriate interventions.…”

“…For instance, in their evaluation of psychosocial care in 11 outpatient medical oncology settings carried out in 11 practice sites in Florida, Jacobsen et al [37] found that emotional well-being was assessed in 52 % of cases, which is much lower than the 87 % adherence percentage obtained in our study. Many studies report various obstacles hindering screening implementation in practice, which include the lack of a screening strategy, and the lack of a management plan to ensure systematic response to screening results [36,38]. HuCare acted on these barriers by requiring centers to outline their own screening strategy, including aftercare following screening.…”

Einführung des Belastungsthermometers auf einer onkologischen Station

“…Wie Untersuchungen zeigten, ist das BT vergleichbar mit umfangreicheren Messinstrumenten sowie mit einem psychiatrischen Gespräch zur Einschätzung des Bedarfs an psychosozialer Unterstützung (Mehnert et al, 2006;Vodermaier et al, 2009;Mitchell, 2010 (Carlson, Waller & Mitchell, 2012;Carlson, 2013;Donovan et al, 2014;Feldstain et al, 2014;Fulcher & Gosselin-Acomb, 2007;Gao et al, 2010;Holland et al, 2010;Mehnert et al, 2006;Söllner et al, 2001;Vodermaier et al, 2009 (Mergenthaler et al, 2011). Dennoch ermöglicht das Ausfüllen des BT im Rahmen eines professionellen Anamnesegesprächs, die Bedürfnisse der Patient(inn)en vollständig zu erkennen, gezielte Interventionen einzuleiten oder eine Überweisung an Fachdienste durchzuführen (Carlson et al, 2012).…”

“…Das Fazit bestand allerdings darin, dass der Nutzen eines Screenings nicht nur vom Instrument, sondern vor allem von äußeren Bedingungen abhängt, beispielsweise von der Nutzung (Mitchell, 2013). Wie Pflegende das Belastungs-Screening einsetzen, [WERT] (27) [WERT] (26) [WERT] (24) [WERT] (24) [WERT] (23) [WERT] (22) [WERT] (21 (Mehnert et al, 2006;Mitchell, 2007 (Carlson, 2013 …”

Validation of the distress thermometer for use among adolescents and young adults with cancer in Australia: a multicenter study protocol

“…47 However, the effectiveness of screening for distress is disputed when it is used independent of a structured referral process or the development of a care plan. 48 Additionally, questions have been raised about whether patients receive appropriate support and access to services without screening.…”