Following patient pathways to psycho‐oncological treatment: Identification of treatment needs by clinical staff and electronic screening

Abstract Objective In this retrospective investigation of patient pathways to psycho‐oncological treatment (POT), we compared the number of POT referrals before and after implementation of electronic screening for POT needs and investigated psychosocial predictors for POT wish at a nuclear medicine department. Methods We extracted medical chart information about number of referrals and extent of follow‐up contacts. During standard referral (November 2014 to October 2015), POT needs were identified by clinical staff only. In the screening‐assisted referral period (November 2015 to October 2016), identification was supported by electronic screening for POT needs. Psychosocial predictors for POT wish were examined using logistic regression. Results We analysed data from 487 patients during standard referral (mean age 56.4 years; 60.2% female, 88.7% thyroid carcinoma or neuroendocrine tumours) of which 28 patients (5.7%) were referred for POT. Of 502 patients in the screening‐assisted referral period (mean age 57.0 years; 55.8% female, 86.6% thyroid carcinoma or neuroendocrine tumours), 69 (13.7%) were referred for POT. Of these, 36 were identified by psycho‐oncological (PO) screening and 33 by clinical staff. After PO‐screening implementation, referrals increased by a factor of 2.4. The strongest predictor of POT wish was depressive mood (P < .001). During both referral periods, about 15% of patients visited the PO outpatient unit additionally to inpatient PO consultations. Conclusions Our results provide evidence from a real‐life setting that PO screening can foster POT referrals, reduce barriers to express the POT wish, and hence help to meet psychosocial needs of this specific patient group. Differences between patients' needs, wish, and POT uptake should be further investigated.

percentage of distressed patients is unrecognised and untreated in clinical practice. [13][14][15][16][17] This is particularly true for patients with thyroid carcinoma (ThyCa) who report to be considered to have "the good cancer," which not only imposes additional burden but also impedes their access to psychosocial care. 18,19 These patients' unrecognised QOL impairments and unmet psychosocial treatment needs have only recently gained attention. 17,20,21 Generally, few patients self-refer to PO counselling, 17,22,23 and health care professionals (HCPs) often fail to identify patients needing psycho-oncological treatment (POT) for reasons such as time constraints, lack of human resources, focus on physical aspects, or difficulties in recognising and addressing emotional problems. 10,12,20 To overcome this problem, it is essential to adequately identify and measure distress in clinical routines, 24 eg, through stepped-care approaches, such as questionnaire-assisted screening followed by personal triage. 5,[25][26][27] In such approaches, it is essential that patients are screened regularly (especially at times of higher risk), screening tools are as comprehensible and as brief as possible, and screening results should be immediately available. The use of electronic screening facilitates data collection, and questionnaire results are scored automatically and easily interpretable. [25][26][27][28] Although distress in patients with cancer is well investigated and promising screening measures have been developed, 5,13,17,26,29,30 little is known about how distressed patients are identified and referred for POT in real world outside a study setting.
We report on an electronic routine screening for QOL impairments and POT needs in a nuclear medicine department. Our main aim was to investigate pathways to POT before and after the implementation of electronic PO screening. We retrospectively analysed data addressing the following aims:

| Patient sample and data extraction
Patients were eligible for PO screening if diagnosed with cancer; older than 18 years; PO naïve (ie, no previous referrals for POT in the hospital); and did not have brain metastases, a diagnosis of dementia, or other cognitive impairments.
Sociodemographic and clinical data, including information on referrals to POT and number and extent of PO consultations, were gathered from hospital charts.
For the investigation of our aims, we extracted data from the following periods: For aims 1 and 2, we extracted data from the standard referral period November 2014 to October 2015, in which routine QOL-monitoring with the QLQ-C30 was paused, and a screening-assisted referral period, November 2015 to October 2016, in which in addition to the PO screening, the QOL monitoring with the QLQ-C30 was started again.
For aim 3, we used data from the same screening-assisted referral period and for comparison extracted data from a standard referral period in which QOL monitoring with the QLQ-C30 had been performed (November 2013 to October 2014).
Linear-converted scale scores range from 0 to 100. High functional scale scores and global health status/QOL scores indicate better functioning and high symptom scale scores represent higher symptom burden.

| PO-screening tool
The screening tool to identify POT needs was constructed by collaboration between the hospital's PO unit and the nuclear medicine department. The tool was based on existing screenings (the Hornheide screening instrument [HSI] short form 34  f) POT: Do you or did you ever suffer from a significantly depressive mood, occurring almost daily over a period of at least two weeks? g) POT: Are you or have you ever been in psychologic/psychotherapeutic/psychiatric treatment or care? Module 2 Anxiety: As patients treated with radiopharmaceuticals must be isolated for several days, we included two questions with a special focus on anxiety attacks that could be answered with either yes or no: "Do you/did you ever suffer from anxiety attacks, in which you felt a sudden intense fear, trepidation, or unrest?" If answered affirmatively, "Are you concerned that you might experience such feelings during treatment?" Module 3 POT wish was assessed using the statement: "We would like to give you the opportunity to talk to a psycho-oncologist during your treatment at our department. Please inform us if you wish to do so" followed by "I would like to talk to a psycho-oncologist" (yes/no).

| Statistical analyses
Sample characteristics are shown as frequencies, means, standard deviations, and ranges.

Aim 1
To describe patient pathways to POT in the 2 different referral periods, we used absolute and relative frequencies.
Aim 2 For the investigation of psychosocial predictors of POT wish, we used binary logistic regression analyses with POT wish (yes/no) as the dependent variable. We included as potential predictors the questions from modules 1 and 2 of the PO-screening tool and, based on findings from previous research 29

| Referrals for POT from standard referral vs screening-assisted referral
In the standard referral period, 28 patients were successfully referred to POT (ie, 5.7% of PO-naïve patients admitted to the department in this period were seen by a psycho-oncologist).
During the screening-assisted period, a total of 114 patients

| Aim 2: identification of psychosocial distress factors associated with POT wish
In the screening-assisted referral period, 86 (30.1% of the 286 patients being screened) exceeded the cut-off for potential POT needs. The most frequent issue reported by patients was a history of or current anxiety attacks.  Only valid percentages are reported. a n = 55 patients. wish and having a history of or current depressive mood reported to be or to have been in psychotherapeutic or psychiatric treatment or care. Patients with and without former psychosocial care uptake differed significantly (P = .002) regarding previous or current depressive mood.

| Aim 3: differences in QLQ-C30 scores between patients identified by standard referral vs PO screening-assisted referral
For the HCP referred subsample 2013/2014, we extracted data of 18  (Table 3). Similarly, no significant score differences were found for the remaining QOL scales.

| CONCLUSION
Although several studies have shown the potential benefits of distress screening for need-based POT, 26,30,35 little is known about the effectiveness outside a study setting. Our investigation was designed to contribute knowledge on this aspect of PO screening.
More than twice as many patients were referred in the screeningassisted referral period than during standard referral.  [20][21][22][23]36 Patients with current or a history of depressive mood were most likely to express POT wish. As those patients were more likely to be or have been in psychosocial treatment or care, the barrier for them to accept professional support could have been lower. However, about half of patients with POT needs refused such treatment. Refusal of POT despite high levels of distress has previously been reported, 22,30 and destigmatisation of psychosocial problems could help in approaching patients in need.
We did not find significant differences in QLQ-C30 scores between patients identified by standard referral vs screening-assisted referral, but results must be interpreted with caution because of the small sample size and because of missing data, which was a result of the routine setting.

| Limitations
The  35,39 Hence, our next steps will be to focus on patients' and HCPs' general acceptance, ways to improve communication during the treatment process, and methods of lowering referral barriers to POT. 35,39 We assume that routine QOL and PO screening has the potential to change the way HCPs look after their patients'