Palliative and supportive interventions to improve patient-reported outcomes in rural residents with cancer

The findings from these 3 research studies were encouraging. In a large randomized control trial of a supportive education program, researchers reported decreased physical symptom intensity after the intervention, however the change did not reach statistical significance.¹⁸ Similar findings were reported in a videoconferencing and a home health program to improve access of palliative and supportive oncology health care.^14,15 Physical symptoms that had decreasing trends were pain, tiredness, and appetite, however, trends for shortness of breath found increasing severity.^14,15 Although these trends were observed, it is important to note that scores on the ESAS did not reach statistical significance for physical symptoms in any of these studies.
 

Reduction in emotional symptom reduction. In addition to reducing physical symptoms, researchers also sought to understand the impact of programs on the emotional symptoms of cancer including: anxiety, depression, negative affect, and posttraumatic stress disorder (PTSD). Five articles included emotional symptoms as an outcome measure. Four were pilot or feasibility studies, and 1 was a randomized control trial.

Results across studies indicated an observable decrease in the severity of anxiety and depression for those exposed to an intervention program.^14,15,18,19 Again, although trends were found, the results were not statistically significant. Only Watanabe and colleagues¹⁴ reported a statistically significant a decrease in anxiety in participants after the implementation of a rural palliative care videoconference consultation program. One report indicated that data on depression severity was collected but was not analyzed because of a small sample size.²¹

O’Brien and colleagues¹⁷ also collected data on negative affect and found that participants who participated in a supportive-expressive therapy group had a reduction in the negative affect as measured by the Derogatis Affects Balance Scale (ABS). Other researchers found no change in emotional distress.¹⁵

Finally, Collie and colleagues²⁰ also measured the impact of a videoconference support group of PTSD symptomology for people with breast cancer in rural areas. Their results indicated a statistically significant decrease on the PTSD Checklist-Specific after intervention. Analysis of the data also found a medium effect size. Participants in the intervention group spoke about how participation in the support group allowed them to be generative and share information about breast cancer as well as build an emotional bond with other women with cancer.
 

Overall quality of life and well-being. Researchers have also looked into impact of intervention on overall QoL. Two articles included QoL or Well-being as an outcome measure. One was a pilot study and 1 was a randomized control trial.

Bakitas and colleagues^18,19 found that those enrolled in the intervention arm of their study had higher QoL scores on the Functional Assessment of Cancer Therapy-General (FACT-G) compared with those in the control arm. These results were also found in an analysis of data from participants who subsequently died during the intervention. Improvements in overall well-being were also found by O’Brien and colleagues¹⁷ using ABS. They reported that a post hoc comparison of participants’ total positive affect score was significantly higher at the 12-month follow-up. In addition, the authors also noted qualitative improvements in well-being, including increased effort to be at the support group and the low attrition rates.
 

Overall impact of rural palliative care on individuals and society. In addition to reducing physical and emotional symptoms in patients, several of the articles also addressed other measures of the overall impact of the intervention or program on society as a whole. The authors evaluated patient satisfaction and quality of life, access to health care services, and financial impact on individuals and society at large.

Satisfaction with intervention. In 2 of the articles, individuals or their family members reported to be satisfied with the intervention^14,20 and said they would recommend it to others as well.²⁰ Both of those studies used teleconferencing to provide access to the intervention to people in rural communities.

Increasing access to the health care services and quality of care. Four of the articles evaluated the impact of intervention on patient’s access to the health care services.^14,16,20,22 Specifically, after the interventions individuals had increased access to palliative care information in rural areas where it had previously been unavailable²⁰ as well as actual delivery of clinical care in their home community, thus eliminating the need to travel to urban areas.^14,20,22 This increase of access to health care services in rural area had significant effect on time and distance spent traveling. In 1 study, the amount of saving in terms of distance was 471.13 km and time in, 7.96 hours, for each visit.¹⁴

In addition, the quality of overall cancer care in rural area was increased. In an early clinical program, to increase access of palliative care in rural communities, the authors reported an increase in the breast conservation from 20% at the start of the program to 70% 2 years after the program was implemented.²² Breast conservation is not a typical outcome for palliative care studies, but the authors highlighted this practice change because of the improved QoL that is associated with the use of breast conservation therapies. In the same study, the authors reported an increased use of curative therapies for other cancers such as lymphoma as well as an increase use of pain management medication.