Feasibility and acceptance of a telehealth intervention to promote symptom management during treatment for head and neck cancer
Patients undergoing treatment for head and neck cancers have a myriad of distressing symptoms and treatment side effects which significantly alter communication and lower quality of life. Telehealth technology has demonstrated promise in improving patient–provider communication by delivering supportive educational content and guidance to patients in their homes. A telehealth intervention using a simple telemessaging device was developed to provide daily education, guidance, and encouragement for patients undergoing initial treatment of head and neck cancer. The goal of this article is to report the feasibility and acceptance of the intervention using both quantitative and qualitative measures. No eligible patients declined participation based on technology issues. Participants completed the intervention for over 86% of the expected days of use. Direct nursing contact was seldom needed during the study period. Satisfaction with the technology and the intervention was very high. In this study a telehealth intervention was shown to be feasible, well accepted, and regularly used by patients experiencing extreme symptom burden and declining quality of life as a result of aggressive treatment for head and neck cancer.
Funding and acknowledgments This research was funded in part by a grant from the National Cancer Institute, National Institutes of Health. This material is the result of work supported with resources and the use of facilities at the Louisville Veterans Affairs Medical Center. Equipment and technical systems were provided through a contract with Robert Bosch Healthcare.
Conflicts of interest The contents of this article do not represent the views of the Department of Veteran Affairs or the federal government. The researchers report no conflict of interest related to the technology used in this study.
Correspondence Barbara Head, PhD, University of Louisville School of Medicine, 511 South Floyd Street, Suite 110, Louisville, KY 40203; telephone: (502) 852–3014; fax: (502) 852–6300
| FREQUENCY | VALID PERCENT | |
|---|---|---|
| Gender (n = 44) | ||
| Male | 39 | 88.6 |
| Female | 5 | 11.3 |
| Race (n = 44) | ||
| Caucasian | 40 | 90.9 |
| African American | 4 | 9.0 |
| Tumor stage (n = 44) | ||
| I | 7 | 15.9 |
| II | 15 | 34.0 |
| III | 11 | 25.0 |
| IV | 4 | 9.0 |
| Unable to determine | 5 | 11.4 |
| Unknown | 2 | 4.5 |
| Site of cancer (n = 44) | ||
| Larynx | 12 | 27.2 |
| Tongue, base of tongue | 7 | 15.9 |
| Unknown primary | 7 | 15.9 |
| Tonsillar | 4 | 9.0 |
| Other H&N sites | 14 | 31.8 |
| Insurance status (n = 44) | ||
| No insurance | 8 | 18.2 |
| Medicaid | 1 | 2.3 |
| Medicare | 2 | 4.5 |
| Medicaid and Medicare | 1 | 2.3 |
| Medicare and supplement | 9 | 20.5 |
| Medicare and VA benefits | 2 | 4.5 |
| Veteran benefits only | 6 | 13.6 |
| Private insurance | 15 | 34.1 |
| Highest educational degree (n = 20)a | ||
| Less than high school | 3 | 15.0 |
| High school or GED | 9 | 45.0 |
| Associate's/bachelor's degree | 4 | 20.0 |
| Masters, PhD, or MD | 2 | 10.0 |
| Other | 2 | 10.0 |
| Income range (n = 18)a | ||
| $20,000 or less | 5 | 27.8 |
| $20,001–50,000 | 5 | 27.8 |
| $70,001–100,000 | 5 | 27.8 |
| Over $100,000 | 3 | 16.7 |
| Percent of poverty in zip code area (n = 44) | ||
| 2.8–5.1% | 11 | 25.0 |
| 5.9–8.6% | 11 | 25.0 |
| 9.0–11.9% | 10 | 22.7 |
| 12.3–45.9% | 12 | 27.2 |
Feasibility and Acceptability
Accrual rate
,Of the 185 patients assessed for eligibility during the 2-year recruitment period, 105 were excluded. See Figure 3 for a detailed depiction of study accrual for both the treatment and control groups. Thirty-three (31%) were excluded because they did not have a land phone line, a requirement for transmitting the algorithms to the Health Buddy appliance. Most of these had cell phones only. No potential participants refused participation due to issues related to operation of the technology itself.
Device utilization
Participants used the telehealth device for an average of 70.7 days (±26.7), which constituted 86.3% (±15.0) of the total days available for use. Of note, the median percentage of use was 94.2% and the modal percentage was 100%, indicating that the vast majority of participants consistently used the telehealth device. The participant with the lowest usage rate used the device 46% of the days available.
By far, the most common reason for Health Buddy nonresponse was patient hospitalization. Two subjects traveled out of town frequently on weekends and would leave the Health Buddy at home. One subject had accidentally unhooked the Health Buddy, and a home visit was made to reconnect the device into the patient's phone line.
Nurse-initiated contacts with participants and/or clinicians
Of the 45 enrolled patients, 33 required additional contact with a research nurse (see Table 3). The most common reasons patients were contacted were nonresponse for 3 consecutive days (38.3%), repeated reporting of high levels of unrelieved pain (30%), and suicidal thoughts (10%). In all, 120 calls were placed: one call for every 25.9 response days. In every case, the problem was resolved.
| NUMBER OF PATIENTS | PROBLEM | OUTGOING CALLS | RESOLUTION |
|---|---|---|---|
| 15 | No response on Health Buddy for 3 consecutive days | 46 | Patient teaching |
| 17 | Pain-related issues | 36 | Advocacy/referral/patient teaching |
| 5 | Suicidal thoughts | 12 | Advocacy/referral |
| 7 | G-tube problems | 8 | Patient teaching |
| 5 | Sadness/depression | 6 | Advocacy/referral |
| 3 | Multiple symptoms | 3 | Advocacy/referral |
| 3 | Nausea/vomiting | 4 | Referral/patient teaching |
| 2 | Coughing/excessive secretions | 2 | Patient teaching |
| 2 | Constipation | 2 | Patient teaching |
| 1 | Stomatitis | 1 | Referral |
Satisfaction ratings
Responses to surveys programmed into the Health Buddy system are displayed in Table 4. Overall, respondents responded favorably, finding the installation to be easy, the content to be helpful, and the overall experience to be positive.
| PERCENT OF RESPONDENTS | |
|---|---|
| Installation satisfaction | |
| Installation problems? | |
| Yes | 2 |
| No | 98 |
| Any difficulty completing the first training questions? | |
| Yes | 7 |
| No | 94 |
| Length of installation? | |
| 2–5 minutes | 52 |
| 6–10 minutes | 41 |
| 11–15 minutes | 4 |
| 16–20 minutes | 2 |
| Content satisfaction | |
| Overall, I think the Health Buddy questions are | |
| Very easy | 44 |
| Somewhat easy | 16 |
| Neutral | 32 |
| Somewhat difficult | 4 |
| Difficult | 4 |
| Repeating questions reinforced knowledge and understanding | |
| Strongly agree | 56 |
| Somewhat agree | 28 |
| Neutral | 12 |
| Somewhat disagree | 4 |
| Strongly disagree | 0 |
| Understanding of my health condition | |
| Much better | 64 |
| Somewhat better | 20 |
| Neutral | 16 |
| Somewhat worse | 0 |
| Much worse | 0 |
| Managing my health condition | |
| Much better | 52 |
| Somewhat better | 44 |
| Neutral | 4 |
| Somewhat worse | 0 |
| Much worse | 0 |
| Recommend the device to others | |
| Very willing | 80 |
| Somewhat willing | 12 |
| Neutral | 4 |
| Somewhat unwilling | 0 |
| Very unwilling | 4 |
| Overall satisfaction | |
| Satisfaction with device | |
| Very satisfied | 45 |
| Satisfied | 35 |
| Somewhat satisfied | 15 |
| Not very satisfied | 5 |
| Satisfaction with the communication between you and your doctor or nurse | |
| More satisfied | 65 |
| No difference | 30 |
| Less satisfied | 5 |
| Ease of using the device | |
| Very easy | 85 |
| Easy | 15 |
| Not easy | 0 |
| Overall experience with the device | |
| Positive | 85 |
| Neutral | 15 |
| Negative | 0 |
| Continue to use the device | |
| Very likely | 40 |
| Likely | 40 |
| Somewhat likely | 15 |
| Not very likely | 0 |
Narrative comments
During the exit interview, participants were asked, “How was having the Health Buddy helpful to you?” Responses could be categorized into two major themes: (1) the Health Buddy provided needed information and (2) the Health Buddy improved my self-management during treatment.
Statements made related to the information provided included the following:
- • It gave me information on what could be expected from treatment
• It was a constant reminder of things to watch for
• It kept me abreast of my total condition at all times
• It gave good directions so I didn't have to ask at the cancer center
• It gave good suggestions on treatments (home remedies) such as gargles, care of feeding tube, exhaustion, and everyday symptoms
Statements made indicative that the Health Buddy improved self-management included the following:
- • I learned what I could do to make myself feel better
• It helped me manage my symptoms
• It taught me about symptom management and how to handle problems
• It let me know whether to contact a doctor or use self-care
• It gave me who to call for problems and some things to try
• It kept me aware of what I needed to do in order to make the period easier
• It reminded me to take my meds and exercise
Additionally, some participants noted the support they felt from having the Health Buddy interventions during treatment in saying the following:
- • It kind of helped my depression through acknowledging it and giving me something to do
• It made me feel I was not the only one who had experience with these things
• It comforted me because I knew what was going to happen
Poststudy survey
Twenty (45%) of the 44 patients who received the intervention responded to the mailed poststudy survey. When asked if they felt they received better care because they had the device, 13 of the 20 (65%) responded that they did. Eighteen (90%) of the treatment group responders stated they were very satisfied with their care (one stated “somewhat satisfied”) and 20 (100%) said they would recommend the cancer center for treatment. Nineteen (95%) stated they received adequate support during treatment.
Outcome Measures
Mean scores on the FACT-H&N and subscales and the MSAS and subscales taken pre-, during, and posttreatment are displayed in Table 5. As expected, average QOL scores declined during treatment, while symptom distress increased, with a return to near baseline scores posttreatment.
