Implementing the NYU Electronic Patient Visit Assessment (ePVA) for Head and Neck Cancer In Rural and Urban Populations

摘要 美国将有大约66,000人被诊断出患有头颈癌 在2022年。大多数HNC患者积极接受多模式治疗，从而提高了存活率 但代价是大量的症状负担，降低与健康相关的生活质量(HRQOL)，以及 广泛应用于急诊护理。HNC患者的症状管理是至关重要的。然而，高达50%的 患者的症状不会被检测到，症状的电子健康记录(EHR)文档是 不完整。突破性研究显示癌症护理过程中的患者报告症状(PRO)监测 与改善症状控制、减少急性护理使用和延长生存时间有关。然而，更近的是 文献调查发现，PRO对癌症预后的影响因实施情况而异。 PRO实施不同的原因包括与电子健康记录(EHR)的集成有限， 获取方面的不平等，以及缺乏标准化方法，为广泛实施 职业选手。我们为HNC开发了纽约大学电子患者访问评估(EPVA)，作为一种有效、可靠的程序 这已经演变成一种临床支持工具，用于早期发现失控症状。EPVA提供了 在护理点自动向临床医生提供患者病情的全球图像，从而实现实时干预。 我们在32名接受放射治疗的HNC患者中完成了ePVA的试点随机临床试验。 (RT)接受或不接受化疗，并发现分配到ePVA+常规护理组的患者报告显著 HNC症状(P&lt；0.05)和急性护理使用(P&lt；.001)比分配给普通护理臂的症状要轻。 我们在这项建议中的目标是确定实施策略，以优化ePVA的有效性，以 改善实际环境中的HNC成果，并探索将ePVA与EHR架构集成 可伸缩性和接入方面的平等。为了实现这一目标，我们将进行混合方法混合第一类研究 在三个国家癌症研究所指定的综合癌症中心为不同的人群提供服务 乡村和城市环境(纽约大学、堪萨斯大学癌症中心、福克斯·蔡斯癌症中心) 使用RE-AIM框架。对于接受RT或不接受化疗的HNC参与者， 具体目标是：1)(定量)确定电子就诊评估(EPVA)对 双臂的HNC症状(主要结果)、疼痛、HRQL和急性护理使用(次要结果) (常规护理与ePVA+常规护理)多点随机临床试验(n=270)；2)(定性)检查HNC 患者和临床医生对患者、临床医生和组织促进者的看法以及ePVA的障碍 覆盖范围、采用、有效性和维护；3)(集成)确定优化的实施战略 EPVA的覆盖范围、采用、有效性和维护；探索目标：探索集成的可用性 EPVA与EHR系统(n=30)。这项研究的长期目标是确定实施和 有效、广泛使用ePVA的技术标准，适用于癌症护理的所有专业人员。

ABSTRACT Approximately 66,000 individuals will be diagnosed with head and neck cancer (HNC) in the United States (US) in 2022. Most patients with HNC are treated aggressively with multi-modal therapies that have improved survival but at a human cost of substantial symptom burden, decreased health-related quality of life (HRQoL), and extensive acute care use. Symptom management for patients with HNC is critical. However, up to 50% of patients' symptoms go undetected and electronic health records (EHR) documentation of symptoms is incomplete. Ground-breaking research shows patient-reported symptom (PRO) monitoring during cancer care is associated with improved symptom control, decreased acute care use, and longer survival. Yet, a closer investigation of the literature finds the effects of PROs on cancer outcomes vary depending on implementation. Reasons for variations in PRO implementation include limited integration with electronic health records (EHR), inequality in access, and lack of standardized approaches, creating barriers to widespread implementation of PROs. We developed the NYU Electronic Patient Visit Assessment (ePVA) for HNC as a valid, reliable PRO that has evolved into a clinical support tool for early detection of uncontrolled symptoms. The ePVA provides a global picture of the patient's condition automated to clinicians at point-of-care, enabling real-time interventions. We completed a pilot randomized clinical trial of the ePVA in 32 patients with HNC undergoing radiation therapy (RT) with or without chemotherapy, and found those assigned to the ePVA+Usual Care Arm reported significantly less severe HNC symptoms (p<.05) and acute care use (p<.001) than those assigned to the Usual Care Arm. Our objective in this proposal is to identify implementation strategies optimizing the effectiveness of the ePVA to improve HNC outcomes in real-world settings and explore integrating the ePVA with the EHR architecture for scalability and equality in access. To achieve this objective, we will conduct a mixed methods hybrid type I study at three National Cancer Institute-Designated Comprehensive Cancer Centers serving diverse populations in rural and urban settings (New York University, University of Kansas Cancer Center, Fox Chase Cancer Center) using the RE-AIM framework. For participants with HNC undergoing RT with or without chemotherapy, the specific aims are: 1) (Quantitative) Determine the effect of the Electronic Patient Visit Assessment (ePVA) on HNC symptoms (primary outcomes), pain, HRQoL, and acute care use (secondary outcomes) in a two-arm (usual care vs. ePVA+usual care) multisite randomized clinical trial (n=270); 2) (Qualitative) Examine HNC patients’ and clinicians’ perspectives on patient, clinician, and organization facilitators and barriers to the ePVA’s reach, adoption, effectiveness, and maintenance; 3) (Integrated) Identify implementation strategies optimizing ePVA’s reach, adoption, effectiveness, and maintenance; Exploratory Aim: Explore the usability of the integration of ePVA with EHR systems (n=30). The long-term goal of this research is to identify implementation and technology standards for effective, widespread use of the ePVA that apply to all PROs in cancer care.