Feasibility and acceptance of a telehealth intervention to promote symptom management during treatment for head and neck cancer
Patients undergoing treatment for head and neck cancers have a myriad of distressing symptoms and treatment side effects which significantly alter communication and lower quality of life. Telehealth technology has demonstrated promise in improving patient–provider communication by delivering supportive educational content and guidance to patients in their homes. A telehealth intervention using a simple telemessaging device was developed to provide daily education, guidance, and encouragement for patients undergoing initial treatment of head and neck cancer. The goal of this article is to report the feasibility and acceptance of the intervention using both quantitative and qualitative measures. No eligible patients declined participation based on technology issues. Participants completed the intervention for over 86% of the expected days of use. Direct nursing contact was seldom needed during the study period. Satisfaction with the technology and the intervention was very high. In this study a telehealth intervention was shown to be feasible, well accepted, and regularly used by patients experiencing extreme symptom burden and declining quality of life as a result of aggressive treatment for head and neck cancer.
Funding and acknowledgments This research was funded in part by a grant from the National Cancer Institute, National Institutes of Health. This material is the result of work supported with resources and the use of facilities at the Louisville Veterans Affairs Medical Center. Equipment and technical systems were provided through a contract with Robert Bosch Healthcare.
Conflicts of interest The contents of this article do not represent the views of the Department of Veteran Affairs or the federal government. The researchers report no conflict of interest related to the technology used in this study.
Correspondence Barbara Head, PhD, University of Louisville School of Medicine, 511 South Floyd Street, Suite 110, Louisville, KY 40203; telephone: (502) 852–3014; fax: (502) 852–6300
Treatment for head and neck cancer is most often a rigorous regimen of combination therapies, producing a multitude of distressing symptoms and side effects. While it is nearly impossible to circumvent the physical and psychosocial insults caused by such treatment, some interventions directed toward educating and supporting patients during active treatment have met with success.[1], [2], [3] and [4] Conversely, other efforts have demonstrated little impact[5] and [6] or have been poorly received,7 pointing to the need for effective, acceptable means to provide support during such difficult treatment.
Over the past 10 years, telemedicine technology has enabled innovative approaches for improving patient education, assessment, support, and communication during treatment for both acute and chronic diseases. A recent policy white paper8 described telemedicine technology as including “the electronic acquisition, processing, dissemination, storage, retrieval, and exchange of information for the purpose of promoting health, preventing disease, treating the sick, managing chronic illness, rehabilitating the disabled, and protecting public health and safety” (p. 2). This same paper suggests that national telemedicine initiatives are essential to health-care reform based upon their proven cost–effectiveness and clinical efficacy. However, cost savings and clinical effectiveness will be unrealized outcomes if the interventions are not feasible in practice or acceptable to the targeted population.
In the arena of cancer care, telephone-based systems have been used to report and monitor cancer symptoms with favorable compliance noted even when patients are expected to initiate calls on a regular basis.[9], [10], [11] and [12] Favorable acceptance ratings have also been reported by both patients and clinicians regarding computerized systems used to assess symptoms and quality of life (QOL) in cancer patients.[13], [14], [15], [16], [17], [18] and [19] In the United Kingdom, a handheld computer system was successfully used to monitor and support patients receiving chemotherapy for lung or colorectal cancer,20 and a study testing a dialogic model of cancer care expecting patients to respond to telehealth messaging on a daily basis over 6 months reported an 84% cooperation rate.21 In these studies, the majority of patients reported ease of use and acceptability of the technology. Survey research has found both urban and rural cancer patients to be receptive to medical and psychiatric services provided via telehealth.22
,Published reports describing use of telehealth and computerized interventions during head and neck cancer treatment are less prevalent. Touch-screen computers were successfully used in the Netherlands to collect QOL and distress data from head and neck cancer patients.16 Videoconferencing has been used successfully to overcome geographical barriers to patient assessment[23], [24] and [25] and to provide speech–language pathology services to people living with head and neck cancers in remote areas. Reported use of telehealth management appears promising for providing timely access to care for those who are geographically isolated.26
A research group based in the Netherlands developed and tested a comprehensive electronic health information support system for use in head and neck cancer care.27 The system had four patient-related functions: facilitating communication between patients and health-care providers, providing information about the disease and its treatment, connecting patients with other patients similarly diagnosed, and monitoring patients after hospital discharge. The system was found to be well-accepted and appreciated by participating patients, and its use enabled early identification and direct intervention for patient problems.27 A clinical trial of the telehealth application showed improved QOL in five of 22 studied parameters for the treatment group.28 However, 20 of the 59 patients eligible for the intervention group refused participation; 11 (55%) of these stated computer-related concerns as their reason for nonparticipation.
Knowing that head and neck cancer patients experience a high burden of illness and often have significant communication, socioeconomic, and geographic barriers to care, our team developed a telehealth intervention using a simple telemessaging device to circumvent communication barriers and perceived technical challenges associated with computer-based systems to provide education and support to patients in their own home and on their own time schedule.29 Overall, we hypothesized that patients receiving the intervention would experience less symptom distress, improved QOL, increased self-efficacy, and greater satisfaction with symptom management than those in the control group. However, as a first step toward examining the efficacy and effectiveness of this intervention, this study examined both quantitative and qualitative indicators of its feasibility and acceptance among patients undergoing treatment for head and neck cancer.
Methods
Design
Subsequent to study approval by the University of Louisville's Human Subjects Protection Office, a randomized clinical trial comparing the telehealth intervention to standard care was conducted using a two-group parallel design. This study reports on the intervention's feasibility and acceptance in the treatment group of 44 patients.
Site
Participants were recruited from patients receiving care from the Multidisciplinary Head and Neck Cancer Team at the James Graham Brown Cancer Center (JGBCC) over a 2-year period (June 2006 through June 2008). The team consisted of head and neck surgeons, medical oncologists, radiation oncologists, nurses, a pathologist, a speech therapist, a registered dietician, a psychologist, and a social worker. This team developed a comprehensive assessment and treatment plan during each patient's initial visit to the clinic and coordinated patient care throughout the treatment process.
Sample
Patients eligible for study participation met the following inclusion criteria: (1) initial diagnosis of head or neck cancer including cancers of the oral cavity, salivary glands, paranasal sinuses and nasal cavity, pharynx, and larynx; (2) involvement in a treatment plan including one or more modalities (ie, surgery, chemotherapy, radiation, or any combination); (3) capacity to give independent informed consent; and (4) ability to speak, read, and comprehend English at the eighth-grade level or above. Patients were excluded from participation if they had no land telephone line, had a thought disorder, were incarcerated, or had compromised cognitive functioning.
All patients scheduled for assessment received an explanation of the research study via print materials prior to their first clinic visit. During their first scheduled clinic visit, all patients identified as eligible were approached by a member of the research study staff, who briefly explained the study and asked if they might be interested in study participation. Because of the stress and content of this first clinic visit, interested patients were contacted later by phone to schedule an additional visit to review the study and obtain informed consent.
During the informed consent meeting, the study procedures were explained in detail. If the patient agreed and signed a consent form, a randomization grid which considered the patient's particular treatment plan was used to assign the patient to either the control or the experimental group. Baseline data were also collected during this first visit.
Description of the Intervention
The technology selected for implementing the intervention was the Health Buddy® System, a commercially available, proprietary system produced and maintained by Robert Bosch Healthcare Palo Alto, CA. The Health Buddy, the appliance used for interaction between the participant and the health-care provider, is a user-friendly, easily visible, electrical device that attaches to the user's land phone line (see Figure 1). Questions and information are displayed on the liquid crystal display (LCD) screen of the 6 × 9–inch appliance. The individual responds to questions by pressing one of the four large buttons below the screen. The research team selected the technology provider based on the ability of the technology to perform in accordance with the research objectives.
