Feasibility and acceptance of a telehealth intervention to promote symptom management during treatment for head and neck cancer

Symptom control algorithms developed using participatory action research (surveys of current and past patients and clinicians) and evidence-based practice were programmed into the telehealth messaging system (see article by Head et al,²⁹ which details the algorithm topic selection and development process). The algorithms addressed 29 different symptoms and side effects of treatment, consisting of approximately 100 questions accompanied by related educational and supportive responses. Patients were asked three to five questions daily related to the symptoms anticipated during their treatment scenario. Depending upon their response, they would receive specific information related to symptom self-management, including recommendations as to when to contact their clinicians. The algorithms were constructed with the goal of encouraging self-efficacy and independent action on the part of the participant. See Figure 2 for an example of the branching algorithms.

Participants randomly assigned to the treatment group immediately had the Health Buddy connected to a land telephone line in their home. Most (40%) chose to place it in their kitchen, while another 26% placed it in their bedrooms; most often, it was in a highly visible location, serving to remind the participant to respond. Research study staff delivered, installed, and demonstrated how to operate the equipment. Installation was simple and required only minutes. A tutorial programmed into the Health Buddy taught participants how to reply to questions appearing on the monitor using the four large keys below the possible answers or a rating scale which would appear depending on the type of question asked.

During the early hours of the morning, the device would automatically call a toll-free number. Responses to the previous day's questions were uploaded, and questions and related information for the next day were downloaded over the telephone line onto a secure server. Phone service was never disrupted by the device; if the phone was in use, the system would connect later to retrieve and download information. Once new content was transferred, a green light on the device would flash to alert the participant that new questions were available for response. Once the participant pressed any of the keys, the new algorithms would begin appearing on the monitor screen.

Participants were instructed to begin responding on the first day they received treatment or on the first day after returning home from surgery. They were asked to continue responding daily (unless hospitalized for treatment) throughout the treatment period and for approximately 2 weeks posttreatment as treatment-induced symptoms continue during that period of time. Study staff contacted participants when treatment was complete and scheduled a date to pick up the appliance and end daily responding. Daily patient responses required 5–10 minutes.

Participant responses could be viewed by study staff via Internet access 1 day after being answered. Responses were monitored daily by study nurses. Symptoms unrelieved over time or symptoms targeted as requiring immediate intervention (ie, serious consideration of suicide) would result in the study nurse contacting the patient directly by phone and/or contacting clinicians to assure immediate intervention. However, it is important to note that this direct intervention by study staff was infrequent as most symptoms were addressed independently by the participant as desired. If a participant had not reported a period of planned hospitalization and did not respond for 3 consecutive days, study staff would contact the patient by phone to ascertain the reason for noncompliance.

Measures

The following indicators were selected as measures of acceptance (accrual rate), feasibility (utilization, nurse-initiated contacts), and/or satisfaction (satisfaction ratings). Narrative responses and a poststudy survey provided additional data examining acceptance, feasibility, and satisfaction with the intervention. In addition, demographic and medical information as well as measures assessing primary study outcomes were collected from each participant. Table 1 lists all measures and the study time point when they were administered.