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
| SCALE/SUBSCALE | PRETREATMENT | DURING TREATMENT | POSTTREATMENT |
|---|---|---|---|
| Total FACT-H&N | 100.3 | 85.6 | 101.5 |
| FACT-G | 74.3 | 69.4 | 78.5 |
| Trial Outcome Index | 62.6 | 46.0 | 65.0 |
| Physical Well-Being | 21.2 | 17.6 | 21.1 |
| Functional Well-Being | 15.6 | 12.5 | 17.4 |
| Emotional Well-Being | 21.1 | 22.3 | 22.2 |
| Social Well-Being | 21.1 | 22.3 | 22.2 |
| Total MSAS | 0.7 | 1.1 | 0.8 |
| Global Distress Index | 1.1 | 1.8 | 1.3 |
| Physical | 0.7 | 1.5 | 1.1 |
| Psychological | 1.1 | 1.2 | 0.8 |
Correlations
The relationships between percentage usage per patient and the following variables were evaluated: age, income, years of education, tumor stage, and percent poverty in patient's zip code. Percent poverty in zip code area was intended to be a surrogate measure of the patient's socioeconomic status. Results are displayed in Table 6. No significant correlations were noted, although years of education and percentage poverty in zip code showed a trend toward significance.
| VARIABLE (VS % USAGE) | RELATIONSHIP | |
|---|---|---|
| SPEARMAN'S RHO RS | SIGNIFICANCE (ONE-TAILED) | |
| Percent poverty in zip code | 0.213 | 0.083 |
| Age | 0.146 | 0.173 |
| Years of education | −0.325 | 0.081 |
| Income | −0.292 | 0.120 |
| Tumor stage | 0.196 | 0.122 |
| Physical Well-Being (during treatment) | 0.310 | 0.048 |
| Emotional Well-Being (during treatment) | 0.315 | 0.042 |
Although a multivariate model was planned, the lack of significant bivariate correlations precluded the need for multivariate analysis.
,When percent usage was correlated with FACT-H&N total and subscales taken at baseline, during active treatment, and posttreatment, significant positive correlations were found between the percentage used and the Physical Well-Being subscale score during treatment (Spearman's rho = 0.310, P = 0.048) and between percentage used and the Emotional Well-Being subscale during treatment (Spearman's rho = 0.315, P = 0.042).
There were no significant correlations between percentage usage and the scores on the MSAS.
Discussion
Both qualitative and quantitative measures indicate that using telehealth to support symptom management during aggressive cancer treatment is both feasible and well-accepted. Patient users were not intimidated by this particular technology as it was simple to set up and use and required no previous computer training to operate. The Health Buddy was viewed as providing important and useful information. Overall, users felt that it improved their ability to self-manage their disease and the side effects of treatment and provided a sense of support and security.
Unlike other studies which use telehealth devices to monitor patient symptoms, our goal was to increase patient self-management of the symptoms experienced during intensive medical treatment, therefore avoiding increased burden on the medical system. The fact that the research nurse overseeing the responses needed to intervene only once every 25.9 days speaks to the ability of the intervention to have a positive impact on utilization of medical services.
The lack of significant relationships between usage and descriptive variables such as age and years of education suggests that the intervention was equally acceptable to all subgroups. Factors such as age, previous computer literacy, educational obtainment, and socioeconomic status did not significantly differentiate our study population in terms of compliance as verified by usage percentages.
The significant relationships found between the percentage used and the subscale scores on Physical Well-Being and Emotional Well-Being during treatment may indicate that increased use of the telemessaging intervention during treatment resulted in better physical and emotional aspects of QOL.
The high rate of daily compliance with the intervention in spite of differentiating personal variables and the severity of the treatment regimen may have been due to one or a combination of the following factors:
- • the simplicity of the technology
• the visibility of the appliance (often placed in the kitchen or living area of the home) and its flashing green light as cues to the need to respond
• the usefulness of the information provided
• the use of simple messaging language presented in an encouraging, positive manner
• affirmations related to application of the symptom management protocols suggested
• curiosity related to the day's messaging and the motivational saying which always appeared at the end
• knowledge that someone was reviewing the responses, tracking and intervening when the participant did not respond for several days
Our study supports the benefits of telehealth interventions noted by providers in a study by Sandberg et al39: opportunities for more frequent contact, greater relaxation and information due to the ability to interact in one's own home, increased accessibility by those frequently underserved, and timely medical information and monitoring. Similar to the study done in the Netherlands,[27] and [28] this study noted technological problems as the primary disadvantage; but in our intervention, we had no problems with the technology or equipment.
Although computerized technology served as a barrier to previous telehealth research, the lack of a land-based phone line was a factor preventing participation in the current study. Indeed, many participants maintained only wireless communication devices, which were not compatible with the version of the Health Buddy that was employed in this study. However, improvements in the technology since completion of this study now allow for wireless access to the appliance or provision of an independent wireless messaging device for those without such access in their own homes.
Although the data generally support the feasibility and acceptability of the telehealth-based intervention, the results should be interpreted in the context of a few study limitations. In particular, the sample size was somewhat small, and data pertaining to the socioeconomic status of participants were not available for all participants. Second, the study did not include measures of the patient's direct interactions with health-care providers during the study or specific data related to their health-care utilization (eg, emergency room visits, preventable inpatient hospitalizations, emergency calls to clinicians). The collection of more exhaustive measures of health-care utilization was limited by resources but is planned for subsequent studies. Finally, concerns regarding subject burden limited assessment of the usability of the telehealth device.
Although compliance with utilization expectations and completion of study measures was excellent during the course of the intervention, response to the follow-up survey mailed several months later was less than 50%. This low response rate was most likely due to several factors: (1) this survey was sent at the conclusion of the entire study (by this time, patients were 0–21 months past their active participation); (2) it was a mailed survey with no additional contact or follow-up effort to increase response rate; (3) participants may have felt that they had already shared their opinions in the exit interview and may have felt overburdened by study measures at this point; and (4) participants may have died, moved, or been medically unable to respond. This lack of response did limit our ability to evaluate the longitudinal impact of the intervention.
Conclusions
This telehealth intervention proved to be an acceptable and feasible means to educate and support patients during aggressive treatment for head and neck cancer. Patient compliance with telehealth interventions during periods of extreme symptom burden and declining QOL is feasible if simple technology cues the patient to participate, offers positive support and relevant education, and is targeted or tailored to their specific condition.
