From Bench to Bedside: Clinical practice examples
Example 3: University Hospital of Besançon - Oncology Unit, France - dayclinic
Background
Over 500 new cancer patients per year start systemic treatment at the oncology outpatient unit of Besançon University Hospital. Each patient has a dedicated encounter with a nurse before initiating therapy. During this encounter, called "caregiver support time", the nurse explains the treatment, the side effects and discusses the patient’s supportive care needs.
A supportive care day hospital was set up at the University Hospital of Besançon in January 2019. It offers patients meetings with several supportive care professionals according to their needs, in a dedicated place and time. Patients can be seen there after their caregiver support time and supportive care needs have been identified, or whenever it's considered necessary by oncologists. Supportive care specialised oncologists coordinate patients' care pathway through the supportive care day hospital.
The electronic PRO measures have been implemented for patients doing the caregiver support time and those treated at the supportive care day hospital since December 2020.
Needs-based supportive care: In the caregiver support time and the supportive care day hospital, ePROs are used to give an overview of patients’ HRQoL and help professionals identify supportive care needs. ePRO data are shared across the involved HCPs.
Included patients: All cancer patients who take part to the caregiver support time and/or attend the supportive care day hospital are included independently of their diagnosis.
Instrument: EORTC QLQ-C30
Assessment times:
- treatment initiation during caregiver support time
- At every visit to the supportive care day clinic
We use ePROs via CHES: patients complete PROMs on tablets, and HCPs review graphical HRQoL scores on computers. CHES applies Giesinger et al.’s clinical importance thresholds1, highlighting domains that should be discussed in red.
Implementation leadership and timing: Implementation was led by a senior nurse, an oncologist, and a research coordinator. Highly motivated HCPs with HRQoL research expertise were a key facilitator. Roll-out in the supportive care day hospital started when the unit was newly founded.
Current status and workflows: HRQoL assessment is now well established, largely due to the senior nurse motivating the team and the research coordinator managing software-related tasks. However, systematic review of HRQoL data during caregiver support time is not yet consistent across all nurses. The senior nurse reviews the data daily if colleagues have not done so.
Data storage and interoperability: Anonymised HRQoL data are stored on CHES servers. Interoperability between CHES and the regional health database is being developed but is delayed for external reasons.
Training: All professionals received individual and group training at implementation start. New staff receives individual training from the research coordinator, covering PROM concepts and use of CHES.
Upcoming study (SOS-DETEQT): A study is about to start to test whether nurse use of HRQoL scores and thresholds for clinical importance improves identification of supportive care needs at treatment start. The study launch will also be used to re-engage professionals and reinforce the importance of reviewing and discussing HRQoL results with patients.
PRO data are displayed in CHES as histogram graphics. Using Giesinger et al.’s thresholds, bars are coloured red or green to indicate whether a domain should be discussed. Results can be viewed for a single time point or longitudinally to track change over time.
As there are no formal interpretation guidelines, evaluation is carried out by nurses and other professionals.
Caregiver support time: Nurses discuss HRQoL results with patients; results can also be documented in the electronic patient record.
Supportive care day hospital: All professionals may discuss HRQoL results, but nurses usually do so. Nurses also review results with oncologists daily (by phone or in person).
Team exchange: A weekly multidisciplinary meeting provides a dedicated space to discuss PRO data.
Actions mainly include adapting supportive care and prescribing supportive treatments.
Currently, there is no systematic feedback, follow-up is mainly nurse-led, and patients do not yet have access to their HRQoL data. We aim to provide standardised feedback for patients, which will be implemented through the SOS-DETEQT study.
Assess IT resources: Teams planning to implement ePROs should first assess the digital environment of HCPs and available IT resources.
Local champion: We recommend identifying a local champion, planning for the necessary human resources, and realistically estimating the time required within the everyday clinical workflow.
1Giesinger JM, Loth FLC, Aaronson NK, Arraras JI, Caocci G, Efficace F, Groenvold M, van Leeuwen M, Petersen MA, Ramage J, Tomaszewski KA, Young T, Holzner B; EORTC Quality of Life Group. Thresholds for clinical importance were established to improve interpretation of the EORTC QLQ-C30 in clinical practice and research. J Clin Epidemiol. 2020 Feb;118:1-8. doi:10.1016/j.jclinepi.2019.10.003. Epub 2019 Oct 19. PMID: 31639445.