Psychology Colloquium: Professor Emerita Phyllis Butow: How hard should we try? Evaluating implementation strategies for embedding an anxiety/depression clinical pathway into routine oncology practice

Professor Emerita Phyllis Butow (USYD)Bio
Prof Phyllis Butow (BA(Hons), MPH, MClinPsych, PhD) is Emeritus Professor in the School of Psychology at the University of Sydney. She founded the Australian Psycho-Oncology Co-operative Research Group (PoCoG) and the Centre for Medical Psychology and Evidence-based Decision-making (CeMPED). Prof Butow has worked for over 30 years leading research in health professional-patient communication and Psycho-Oncology. She has conducted research on psychosocial issues in cancer genetics, doctor-patient communication, patient involvement in cancer consultations and decision-making (including informed consent), interventions to reduce fear of cancer recurrence, implementation of clinical pathways for anxiety and depression in cancer patients, and disparities in outcomes and needs of immigrants with cancer. She has won many awards, including the International Psycho-Oncology Society Bernard Fox award for outstanding contribution to Psycho-Oncology research in 2009, the Clinical Oncological Society of Australia Tom Reeve award for outstanding contribution to cancer care in 2011, NSW Cancer Researcher of the year in 2012, and an Order of Australia (AM) in 2014.
How hard should we try? Evaluating implementation strategies for embedding an anxiety/depression clinical pathway into routine oncology practice
Abstract
Background: Evidence on the efficacy of psychosocial oncology interventions is mounting, yet their inclusion in routine clinical practice remains low. Optimal strategies to facilitate implementation of evidence-based clinical pathways are unclear. Implementation science must guide the next wave of research in our discipline. We developed a clinical pathway for anxiety/depression (the ADAPT CP) and resources to support it, including health professional (HP) training, an online patient intervention and HP and patient portals to facilitate the process. We evaluated two implementation strategies (core versus enhanced) to facilitate implementation of the ADAPT CP in routine care.
Methods: Twelve cancer services in NSW Australia were cluster randomised, stratified by service size, to a core (standard) versus enhanced (more proactive, ongoing support by the research team) implementation strategy for the ADAPT CP over 12 months. All patients at participating sites were offered the ADAPT CP as part of routine care, and if agreeable, completed screening measures at regular intervals. They were allocated a severity step for anxiety/depression from one (minimal) to five (severe) and recommended management appropriate to their severity step. Staff completed questionnaires and interviews prior to, and at 6 and 12 months after implementing the ADAPT CP. Health economic data were collected.
Results: Of 1,280 registered patients, 696 (54%) completed at least one screening, and there were 1,323 screening events (883 in core and 440 in enhanced services) in total. Adherence was high for screening, moderate for referral and low for checking uptake and progress. Adherence was significantly higher when anxiety/depression step was less severe, and in the enhanced versus control arm (p=.02) for step 3 anxiety/depression and trending to significance for step 4. Anxiety/depression dropped significantly between screens. Health service costs (attending medical appointments, use of drugs) were lower in patients following registration on ADAPT CP. The cost of implementing ADAPT CP for individual services was approximately $12,000 a year. Staff perceived the CP as of high value, acceptable, appropriate, fit for purpose for services and a catalyst for change. However, timing screening was difficult, online screening was challenging and burdensome, and referral pathways were sometimes unclear.
Discussion: These results support ongoing implementation effort for the first year of implementation to ensure successful uptake of new clinical pathways in over-burdened clinical services. We need to understand the barriers and facilitators of uptake for psychosocial oncology interventions, and ensure that appropriate resourcing is allocated for this purpose.