| | Evaluation of a face-to-face psychosocial screening intervention for cancer patients: Acceptance and effects on quality of lifeReceived 28 March 2007; received in revised form 3 September 2007; accepted 16 September 2007. Abstract ObjectiveThis study evaluated a psychosocial screening intervention that offers cancer patients counselling. The assumption underlying the intervention was that barriers are often present that hamper patients’ awareness of and active request for psychosocial care. An active yet unobtrusive approach was hypothesized to improve accessibility to psychosocial services. ResultsHalf the screening group actually wanted and received counselling. At follow-up, the screening group reported significantly less pain, better mental health and better physical and role functioning than the usual care group. ConclusionThe face-to-face screening intervention appears an effective means of identifying patients interested in obtaining formal psychosocial counselling, and may result in improvements in physical and mental health outcomes. Practice implicationsThis screening intervention may be particularly useful for hospitals that prefer a personal approach to psychosocial screening, but do not have sufficient resources to interview every new patient. 1. Introduction  A diagnosis of cancer has enormous impact on both patients and their families. Although survival rates have improved, the diagnosis is often experienced as a confrontation with impending death. This places significant demands on the patient's ability to cope with both the disease and its treatment. Not surprisingly, the prevalence of mental health conditions in cancer patients is high. Clinical experience and empirical studies have confirmed that cancer patients are at risk for developing depression, anxiety, and other forms of psychological distress [1], [2], [3]. Psychosocial interventions have been shown to be effective in alleviating mental health symptoms and thereby in improving quality of life and daily functioning [4], [5]. To a certain extent, psychological distress can be viewed as a normal reaction of patients and their families to an extremely stressful situation. Many patients are able to handle their situation emotionally without formal professional assistance. Other patients, however, can benefit from professional intervention. The challenge to clinical practice is to distinguish between self-limiting distress and distress reactions that may require more formal intervention. In most hospitals, some form of professional psychosocial intervention is available to patients via self-referral or referral by a health care professional (e.g., a physician or nurse). However, reliance on such ad hoc referrals may lead to an under-recognition and under-treatment of mental health problems [6], [7], [8]. Consequently, screening programs aimed at timely recognition of psychosocial problems have been developed. Broadly speaking, two methods of screening for psychosocial problems are available: standardized self-report questionnaires and semi-structured interviews. Screening with questionnaires such as the Hospital Anxiety and Depression Scale [2], [9], [10], [11], [12] or the Brief Symptom Inventory [11], [12], [13] is relatively inexpensive and efficient, and can be recommended in situations where large numbers of patients need to be screened and resources for carrying out the screening are limited [14]. However, screening via questionnaire carries with it a number of potential limitations. The available standardized questionnaires typically screen for high levels of psychological distress scores or psychiatric caseness. Emotional reactions that have not (yet) developed into a serious disorder, as well as other relevant psychosocial concerns (e.g., problems with family communication and relationships, concern about the future, practical and financial issues) are likely to remain undetected. Screening for psychosocial problems via personal interviews can take on a broader focus, facilitates detecting problems at a relatively early stage, and offers patients the opportunity to elaborate on their illness and treatment experience, and thus may have some therapeutic value in and of itself. Some have even suggested that an improved mental health of cancer patients may contribute to their physical health and chances of survival, although the empirical support for this link is inconsistent [15]. Weisman and co-workers have developed and tested a screening procedure that employs a structured interview with every patient [13], [16]. This approach, while effective in identifying patients’ needs, is costly and potentially inefficient in that a relatively large amount of time is devoted to interviewing and screening patients who will not require psychosocial intervention [14]. We therefore adopted a modified approach whereby at hospital admission, every patient is offered a face-to-face contact with a psychosocial professional “to find out how the illness and the treatment affect life and how, given these circumstances, the patient is doing.” Patients are free to decide if they wish to have this face-to-face contact, but in any case all patients are made aware of the availability of psychosocial services. The assumption underlying this approach is that most patients are able to indicate whether or not they need psychosocial services, but opportunities to indicate such needs are often not present. An active but unobtrusive approach to assessing patients’ perceived needs for psychosocial care and for informing patients of the services that are available might improve accessibility to care. A pilot feasibility study of this approach to screening for psychosocial care needs carried out at the VU University Medical Center in Amsterdam yielded encouraging results [17]. The current study was undertaken to evaluate the efficacy of the screening intervention in a more rigorous manner, including use of a control group and follow-up assessments. The primary objectives of the study were to determine the uptake of a face-to-face screening contact by cancer patients admitted on an inpatient basis, and to evaluate the effects of the screening intervention on actual care provided and on patients’ self-reported psychosocial well-being. Three specific research questions were addressed. First, how many patients accept the offer of a face-to-face contact with a psychosocial professional? Second, does the use of a structured screening intervention result in more referrals to psychosocial care than the usual care situation which is characterized by ad hoc referrals? Finally, does the availability of a structured screening program have a positive effect on patients’ mental health and psychosocial well-being as assessed 4 weeks following the screening? 2. Methods 2.1. Study sample and design The study sample was composed of patients admitted as inpatients in the Department of Medical Oncology of the VU University Medical Center in Amsterdam. Patients were included in the study if this was their first admission or re-admission after more than 24 months. Patients were excluded if their physical condition was extremely poor (e.g., terminal stage of disease), if they suffered from severe cognitive impairment, or if they did not have basic fluency in the Dutch language. The study employed a sequential cohort design with repeated measures. An initial cohort of consecutive patients admitted on an inpatient basis formed the usual care control arm of the study. A second cohort of consecutive patients formed the experimental arm of the study. A second, medical records, control group was formed by extracting information from the medical records of all patients who were admitted to the department of oncology in the 4 month period preceding the usual care period. This sequential cohort design was deemed the most appropriate means of testing the effect of the screening intervention, given the practical and ethical constraints involved. A classical, randomized control group design was considered infeasible and inappropriate in that patients are treated in multiple-bed hospital rooms. The likelihood that patients randomly assigned to a usual care control group would become aware of the intervention via patients assigned to the experimental group was deemed considerable, and thus there was a significant risk of a “contamination” effect [18]. 2.2. Study procedures During both the usual care and the intervention period, the head nurse informed all new patients who fulfilled the inclusion criteria about the study, and provided written information and an informed consent form. On the following day, a social worker or psychologist (=intaker; FE, MK, MvK, MvdL or JS) visited the patient to determine whether (s)he wished to participate in the study and, if yes, to obtain informed consent. Consenting patients were asked to complete a set of questionnaires on the same day. A second set of questionnaires was sent to the patient by mail approximately 4 weeks following discharge from the hospital. Prior to mailing the follow-up questionnaires, the patients’ vital status was checked via the patients’ general practitioner. The study was approved by the institutional review board of the VU University Medical Center. 2.3. The face-to-face psychosocial screening intervention The intervention was introduced by the head nurse as a possibility to talk with a member of the psychosocial team ‘about how the illness and the treatment were affecting the patient's life and how, given these circumstances, the patient was doing’. Patients also received an information leaflet. On the following day, a psychologist or a social worker visited the patient to determine if (s)he wished to talk with a member of the psychosocial team. If so, a semi-structured interview was conducted using a checklist (see Section 2.4). The interview ended with a summary of the patient's psychosocial situation and his or her capacity to deal with that situation. The intaker explicitly inquired whether the patient wanted a follow-up contact. If not, the contact was ended and the patient was informed that, if the situation or needs changed, (s)he could always approach the psychosocial team. If a follow-up contact was requested, a summary with conclusions was placed in the medical record and a subsequent appointment was made. In addition, patients were discussed in the weekly multidisciplinary meeting. 2.4. Measures Upon hospital admission and at follow-up, the patients completed: (a)The EORTC quality of life questionnaire (QLQ-C30, version 3.0) [19] which measures physical, role, emotional, cognitive and social functioning, global health status/quality of life, three major symptoms (pain, emesis and fatigue) and six additional symptoms. Most items employ a four-point response scale varying from “not at all” to “very much”. The two items assessing global health status/QoL are rated on a seven-point scale varying from “very poor” to “excellent”. The reliability and validity of the QLQ-C30 is well documented [19]. (b)The General Health Questionnaire (GHQ-12) [20] which screens for mental health problems. Twelve items are answered on a four-point scale. The negative subscale assesses presence of psychopathology (e.g., sleeping problems), while the positive subscale measures psychological health (e.g., being able to concentrate). Patients compare their current situation to their “usual” situation. Deviations from the usual situation are counted so that higher scores are indicative of psychopathology. (c)At follow-up, patients also completed the Impact of Event Scale (IES) [21], [22] that measures the emotional impact of the illness. The 15 items assess intrusion (7) and avoidance (8) during the past 7 days. The IES employs a four-point response scale varying from “not at all” to “often”. The psychologist or social worker (=intaker) used a structured checklist to guide the semi-structured interview that formed the core of the intervention. Eleven topics are addressed starting with an open-ended question (“Overall, how would you describe your current situation”), followed by a series of specific questions pertaining to current physical condition and treatment, current emotional condition, social network and living circumstances, religion or philosophy of life, medical history, life events, personality and coping, history of psychosocial care, future perspective, any other issues, and overall balance between perceived burden and coping capacity. Where appropriate, the intaker probed for additional information (e.g., “Can you tell me more about it?”). For each topic, the intaker rated the presence of problems and needs on a four-point Likert-type scale: 0 (no special attention needed, no vulnerabilities), 1 (mild problems, no special attention needed), 2 (problems that require attention/care), and 3 (serious problems that require immediate action). At the end of the interview, the intaker discussed with the patient whether a follow-up contact was desired and/or necessary. The intaker also documented the duration of the contact, presence of others, the degree to which the patient was able to communicate, and the availability of a private interview space. For all three study groups (usual care control, intervention, and medical record control), the following information was extracted from the medical records: hospital admission date, gender, date of birth, full diagnosis, first illness episode or relapse, month and year of current illness episode, and, if applicable, month and year of first illness episode, medical treatment, and referrals to psychosocial services. 2.5. Data analysis First, the usual care and the screening group were compared with respect to background variables, and baseline scores on the QLQ-C30 and the GHQ-12 scores. The medical record group was compared to the other two groups with respect to background variables only. The first and second research questions were addressed using descriptive statistics, t-tests, and chi-square tests. The third research question was addressed using a series of multiple regression analyses with the QLQ-C30, GHQ-12 and IES scores at follow-up as dependent variables, and group membership as the independent variable. In each analysis, the pertinent QLQ-C30 or GHQ-12 score at baseline was entered as a covariate together with gender, age, and level of education. Since the IES was administered only at follow-up, the GHQ-12 score at baseline was entered to control for differences in mental health at baseline. 3. Results 3.1. Sample recruitment In the usual care period of 15 weeks (April–July 2000), 72 new patients were admitted to the department of oncology. Two patients did not speak Dutch and 6 patients were excluded because their physical or mental condition did not allow participation in the study, thus resulting in 64 patients who fulfilled the inclusion criteria. Of these 64 patients, 3 were not successfully approached for study participation due to a very short period of hospital admission or to a very busy schedule during the hospital stay. Eleven patients declined the invitation to participate for diverse reasons (e.g., too tired, no perceived need, other priorities). Fifty patients (78%) participated at baseline. At the time of hospital discharge, 31 patients gave written permission to send them a follow-up questionnaire, 15 declined to participate in the follow-up, 1 patient was too ill to ask permission, and 3 patients could not be contacted prior to discharge. Twenty-eight patients returned the follow-up questionnaire (44% of the initial 64 patients). During the 24 week intervention phase of the study (July 2000–January 2001), 116 new patients were admitted. One patient did not speak Dutch. For four patients, their physical or mental condition did not allow for participation. Another two patients were excluded because they already had contact with social work following outpatient treatment. Of the remaining 109 patients fulfilling the inclusion criteria, 8 were not reached and 22 declined to participate. Thus 79 patients (72%) participated at baseline. During admission, 4 patients died and 3 patients were deemed to be too ill to ask permission for further participation. Thirty-five patients gave permission to send the follow-up questionnaire, of whom 28 responded (26% of the original cohort of 109 patients). In the 15 weeks preceding the usual care period (December 1999–April 2000), 96 new patients were admitted to the department of oncology. Seven patients did not speak Dutch (this eligibility criteria was maintained to maximize comparability with the other two groups) so that 89 patients were included in the medical records group. 3.2. Patients’ baseline characteristics At baseline, the three groups were not significantly different with respect to age, gender, marital status, duration of hospital admission, primary diagnosis, first illness episode/relapse, duration of current illness episode, and focus of treatment (see Table 1). The most frequent primary diagnoses were: cancer of the digestive organs (39%), breast cancer (16%), and head and neck cancer (16%). The usual care group had a significantly lower level of education than the screening group (p <.01). No significant group differences were found on the baseline scores of the QLQ-C30. On the GHQ-12, patients in the usual care group reported significantly more symptoms at baseline (M=5.19; S.D.=2.98) than the screening group (M=4.03; S.D.=3.55; p<.05). 3.6. Research question 3: quality of life and mental health at follow-up Table 2, Table 3 show the mean scores of the screening group and usual care group follow-up samples on the QLQ-C30, GHQ-12 and IES at baseline and at follow-up, as well as the results of a series of multiple regression analyses that examined between group differences in these scores at follow-up, controlling for relevant baseline variables. A statistically significant difference favoring the screening group was found in the change from baseline to follow-up on the QLQ-C30 ‘pain’, ‘physical functioning’, and ‘role functioning’ scales. The usual care group reported decreased physical and role functioning and increased pain levels, while the screening group reported no changes in physical and role functioning and a decrease in pain levels. In addition, the screening group scored significantly better on the GHQ-12 positive mental health scale than the usual care group, reflecting such things as being better able to concentrate and to obtain pleasure from normal daily activities. We note that, in total, 19 subscales were tested. On the basis of chance, one would expect one significant between group difference to emerge from the analysis, while we detected significant differences on four of the outcome measures. 4. Discussion and conclusion 4.1. Discussion This study evaluated the effect of a screening intervention that actively but unobtrusively offered newly admitted cancer inpatients a face-to-face contact with a psychosocial professional. The most important finding is that the group that received the screening intervention reported significantly less pain, better physical functioning and role functioning and better mental health. These results are in line with studies reporting a positive effect of psychosocial interventions on quality of life and symptoms of psychological distress [4], [5]. Approximately half of the patients actually wanted and ultimately received some form of counselling. Nevertheless, a significant effect on psychological and physical well-being was detected in the group as a whole. That the offer of formal psychosocial support was accepted by approximately half of the patients suggests that there is a large need for psychosocial care in this population of cancer inpatients. However, we would note that this figure may not be generalizable to other hospitals and settings because our hospital offers experimental treatment to patients who often have undergone first line treatment in other settings. Therefore, the patient census includes a relatively large percentage of patients with a poor prognosis and who are very ill. During the screening period the number of referrals to psychosocial care was higher than in the usual care period. The medical records group held an intermediate position. Our a priori expectation was that the number of referrals in the medical record group would be significantly lower than in the screening group and approximately the same as in the usual care group. The most likely explanation for the relatively high number of referrals in the medical records group is that the exclusion criteria could not be applied in the same manner as in the two other groups, where the nurse determined whether the patient was eligible for the study, i.e. not “too ill” or not approachable. We believe, therefore, that the comparison of the screening group with the usual care group provides the best estimate of the effect of the intervention on the rate of referrals to psychosocial services. The short admission duration and busy diagnostic and treatment schedule of the patients made it difficult for the screening procedure to be offered to all patients. During the study, the timing of the offer for psychosocial services was therefore frequently discussed. Our team concluded that it would perhaps be best to repeat the offer several times during treatment, so that patients who are in need can select a moment that is most convenient for them. The study had several limitations that should be noticed. First, while at baseline the response was quite good (above 70%), at follow-up this percentage decreased to 44% for the usual care and 26% for the screening group. The decreasing participation rate was due primarily to the fact that this group of patients was seriously ill. Many patients found participation too burdensome and four patients died during hospitalization. In this very ill group of patients receiving burdensome treatments, we knew that it would be difficult to reach each patient for participation in the study. For ethical reasons, no pressure was exerted on them to participate. Second, since random assignment to the usual care or intervention group was not deemed feasible in this treatment setting, the study employed a quasi-experimental design [18]. While we have no evidence to suggest that there were any serious threats to the internal validity of the study (e.g., a history effect), this cannot be ruled out entirely. Non-response, attrition and study design may have resulted in pre-existing differences between the usual care and the screening groups in both the larger baseline sample and in the smaller follow-up sample. Two analyses found no significance between group differences on most variables. However, statistically significant between group differences were detected on two variables in the baseline sample (education and GHQ-12) and on four variables in the follow-up sample (age, gender, GHQ-12, and insomnia). Moreover, there was a differential attrition from baseline to follow-up for the usual care and the screening group. In the usual care group, the proportion of women decreased from baseline to follow-up, while in the screening group the proportion of lower educated patients, younger patients, and patients with a better mental functioning and less sleeping problems increased from baseline to follow-up. As a result, the analyses examining the effect of the screening intervention are based on a small and in some aspects selected group of patients: the screening group included more women, more younger patients, and more patients reporting a better mental health and less sleeping problems at baseline than the usual care group. An important question is, whether these differences might have biased the results, and might form an alternative explanation for the positive treatment effect? This seems unlikely, because the largest treatment effect would be expected for patients with more mental health problems. The group differences that were detected showed better baseline mental health in the screening group. Therefore, it is more likely that the effect of the intervention was underestimated in this study. We note further that this ‘underestimation effect’, if present, is probably small, because with respect to admission duration, marital status, first illness episode, duration of current illness episode, medical treatment focus, IES, and most scales of the EORTC, no indications for selective or differential attrition were found. Furthermore, in the follow-up regression analyses, statistical adjustments were made for age, gender, education, and relevant baseline mental health scores. In summary, it seems unlikely that the positive treatment effect was due to selective sampling. Nevertheless, we cannot completely rule out that unmeasured chance effects may have played a role in producing the results. [23] Therefore, further research is necessary, preferably with higher response rates, resulting in larger and less selective samples, to confirm our findings. 4.2. Conclusion The results of this study suggest that a face-to-face screening intervention leads to an improvement in the provision of psychosocial care as compared to an ad hoc referral process. In turn, the increased provision of such services contributes to lowering the rates of psychological distress and improving the quality of life of patients. Additional research is needed to confirm these results. 4.3. Practice implications We would recommend this approach to hospitals that prefer a personal approach to screening for psychosocial problems over the questionnaire method, but do not have sufficient resources to screen all newly hospitalized patients via an interview. Ideally, implementation of this approach should be guided by further research. Acknowledgements The study was financially supported by a grant from the “Platform Vrouwen VU-hulp”. We thank M. Kersloot, M. van Koolwijk, and J. Slikkerveer for carrying out the psychosocial screening intervention, and for contacting patients in the usual care period. We thank W.H.J.J. Cleijne, A.J.P. Oggel, and I.E.W. Reuling for their assistance. The nurses of the oncology unit, particularly M. van Dullemen and M. de Koning, also provided invaluable assistance. References [1]. [1]Derogatis LR, Morrow GR, Fetting J, Penman D, Piasetsky S, Schmale AM, et al. The prevalence of psychiatric disorders among cancer patients. 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a Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands b Department of Medical Social Work, VU University Medical Center, Amsterdam, The Netherlands c Division of Psychosocial Research & Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands d Department of Medical Oncology, VU University Medical Center, Amsterdam, The Netherlands  Corresponding author at: Freesiadal 22, 2317 HN Leiden, Amsterdam, The Netherlands. Tel.: +31 71 5223327.
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