What models of care for teleoncology are available to allied health services?

From Cancer Guidelines Wiki

Introduction

Reviewing the models of care used by allied health professions in the area of teleoncology revealed variations in the types of technology currently used. The following sections are grouped by technological approach, with separate evidence summaries and recommendations made regarding: telephone-based services; computerised screening and assessment, hybrid education and health monitoring services; and videoconferencing services.

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Telephone-based services

There have been a number of Level II (most with moderate bias)[1][2][3][4][5][6][7][8][9][10][11][12] and lower level III/IV[13][14][15][16][17][18][19][20][21][22][23][24] studies confirming positive effects of telephone services to support allied health interventions across a range of oncology populations. Despite this, it is important to note that no studies have directly compared the delivery of the same intervention by traditional face-to-face services with the telephone-based service. As such, the current evidence supports the feasibility and benefit of delivering aspects of allied health care by telephone, however, their equivalence to face-to-face services is unproven.

Most of the research in this area has been conducted with breast cancer patients. Studies have documented the positive impact of telephone education and counselling sessions targeting psychosocial functioning for individuals (including males)[1][2][13][3][4][14][7], or their first degree relatives.[15] Such services were typically delivered by social workers,[1][2][13][4] masters level psychosocial counsellors[4][15] or experienced group therapists.[13]

Other studies have demonstrated improved physical activity using telephone support programs administered by exercise physiologists.[5][16] Individuals also experienced positive treatment effects for functioning, emotional state and quality of life from occupational therapy interventions.[7]

Telephone-based interventions have some benefits for lifestyle change,[19] for reducing behavioural risk factors[17] and improving sexual and intimacy outcomes in patients with colorectal cancer and their partners.[8][18] Use of telephone contact to support home-based exercise programs[20][9], deliver combined exercise, nutrition and counselling services[21][10][11] or psychological therapy[22], have demonstrated improved nutritional states,[21][10][11] enhanced physical wellbeing[20][9][21][11] and positive psychological benefits[21][10][11][22] in both population specific[10][23] and mixed groups of cancer survivors.[20][9][21][11]

Telephone counselling services were not found to enhance smoking abstinence rates amongst people in the social networks of patients with lung cancer.[12] A pilot trial of a pharmacist-led service using telephone SMS monitoring was found to be a feasible method for monitoring chemotherapy induced side effects in ambulatory outpatients receiving chemotherapy.[24]

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Computerised screening and assessment

The use of technology-assisted screening tools for the assessment and monitoring of oncology patients is still in an early stage of development. Five lower level evidence (IV) studies have reported on the use of computerised screening tools as a model of care in oncology outpatient settings.[25][26][27][28][29] Three of these studies specifically focused in the head and neck cancer population[26][27][28] and two in generalised ambulatory oncology patients.[25][29]

All these studies reported on purpose-built touch screen computer systems delivering patient-reported outcome measurements, including speech and swallowing function, pain, distress, and overall quality of life. Only one study has investigated the implementation of a computerised screening tool to direct psycho-oncology services. This resulted in a greater numbers of referrals and a reduction in overall patient-reported distress post-service implementation.[29] One investigation reported on the feasibility of a computerised quality of life screening program as a model of care.[25] The three remaining studies reported on utilisation of screening tools to collect prevalence data on patient-reported functional deficits or concerns. These studies contained limited discussion on the integration of the tools into their own clinical service model.[26][27][28]

Overall, the evidence for the use of computerised screening and assessment tools by allied health professionals is still emerging. However, preliminary findings suggest that it is feasible to integrate these models into clinical services.

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Hybrid education and health monitoring services

There is a limited body of evidence for the use of technology-enabled hybrid systems by allied health professional working in oncology services.[30][31][32][33][34] A Level II randomised controlled trial demonstrated favourable quality of life outcomes for patients who received a combination of computer-based support and face-to-face mentoring by clinicians.[32] A lower level follow-up study of the same system reported improvements in caregiver burden and mood.[30]

A Level IV study reported the value of a computer-based support and monitoring system in communicating emergent clinical issues as well as facilitating patient education.[34] Two studies investigated the use of web-based support groups for breast cancer survivors moderated by allied health professionals, with high participant satisfaction and a moderate positive effect on depression and cancer-related trauma.[31][33]

While the evidence-base is preliminary at best, the use of hybrid teleoncology systems incorporating web-based education and remote interaction by allied health professionals may have merit for enhancing the reach of finite health resources.

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Videoconferencing services

The allied health professions that currently use videoconferencing for oncology care are pharmacy, physiotherapy, psychology, social work, and speech pathology.[1][35][36][37][38][39][40][41][42][43][44] The technology used is standard hardware and videoconferencing software with specialised peripheral devices such as head-set microphones[43] and medical camera systems[35] to enable remote assessment of routine clinical structures and features such as voice quality or oral cavity.

Of the eleven published studies, two were Level II, three were Level III randomised controlled trials, while the remaining were Level IV case series. Both Level II studies evaluated the use of videoconferencing to improve patient access to a psychosocial intervention. One study compared the effectiveness of telephone health education and interpersonal counselling delivered by videophone or telephone for breast cancer survivors and their supportive partners.[1] While increased quality of life was noted for all participants, individuals in the telephone or video teleconferencing counselling groups experienced increased social well-being. The other study evaluated the outcomes of an online mindfulness-based cancer recovery group program compared with a usual treatment group. Moderate positive effects in mood disturbance, stress symptoms and some aspects of mindfulness was experienced by the group accessing treatment by videoconference.[44]

Both Level III studies reported successful use of videoconferencing in the provision of telerehabilitation. These included a reliable clinical model for the remote assessment of swallowing and communication function in patients post laryngectomy[43] and the validation of an online assessment method used by carers to monitor and detect lymphoedema in breast cancer survivors.[37]

The remaining lower level studies (Level IV) describe case series using videoconferencing for multidisciplinary allied health assessment and treatment in a head and neck cancer clinic[41] and palliative care.[42] These studies described the benefits of videoconferencing in enabling better access to specialist care and support,[35][38] and positive patient outcomes for communication and swallowing rehabilitation[35] as well as psychological benefits.[36][39][40]

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Evidence summary and recommendations

Recommendation One

Evidence summary Level References
Telephone-based services have demonstrated benefit in the delivery of allied health cancer care services for psychology, social work, occupational therapy, exercise physiology, physiotherapy, nutrition/dietetics and pharmacy models of care. II, III-1, III-2, III-3, IV [1], [2], [13], [3], [4], [14], [15], [5], [6], [16], [7], [17], [8], [18], [19], [20], [9], [21], [10], [11], [22], [23], [12], [24]
Evidence-based recommendationQuestion mark transparent.png Grade
Telephone-based support systems are feasible and can help facilitate changed behaviours (eg. diet, exercise), improved function (eg., fitness, health related function), and improved psychological/psychosocial states.
B


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Recommendation Two

Evidence summary Level References
Computerised screening models have demonstrated benefit in the assessment and monitoring of speech, swallowing, quality of life, pain and distress in allied health oncology outpatient settings. IV [25], [26], [27], [28], [29]
Evidence-based recommendationQuestion mark transparent.png Grade
Computerised screening/assessment is feasible and can be used as a model of care to collect information on patient status and assist referral to allied health oncology services.
C


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Recommendation Three

Evidence summary Level References
Hybrid telepractice systems have demonstrated benefit in the delivery of allied health cancer care services for psychology models of care, and multidisciplinary patient education. II, IV [31], [30], [32], [33], [34]
Evidence-based recommendationQuestion mark transparent.png Grade
Hybrid telepractice systems can offer alternative models of care for the provision of allied health education and support to oncology patients.
C


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Recommendation Four

Evidence summary Level References
Videoconferencing has demonstrated benefit in the delivery of allied health cancer care services for pharmacy, physiotherapy, psychology, and speech pathology telepractice models of care. II, III-1, III-2, III-3, IV [1], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44]
Evidence-based recommendationQuestion mark transparent.png Grade
Videoconferencing services can be used to deliver allied health assessment and treatment services for oncology patients.
C


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Practice Point

Practice pointQuestion mark transparent.png

Equivalency to standard/usual care has been reported for some allied health telepractice models. Clinicians should refer to individual studies to determine the similarity in outcomes with their chosen model of care.

References

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Appendices