Our presentation this year at the 2018 SIOG Annual Conference is related to caregiver satisfaction as a result of a geriatric assessment intervention. The study was funded by the Patient-Centred Outcomes Research Institute and the National Cancer Institute at the University of Rochester where I work and lead the programme in geriatric oncology there. We’re affiliated with a community oncology practice structure that’s national called the NCI Community Oncology Research Programme, or NCORP, and it’s funded by the United States government through the National Institute on Health. It allows us to do rigorous scientific randomised controlled studies in community oncology practices across the country in the United States.
As we know, older patients with cancer commonly see their community oncologist and are more rarely going to academic centres so community oncologists are really faced with trying to develop treatment plans for not just older patients with cancer but also their caregivers. Our research has shown that caregivers have high levels of distress in the care of older patients with cancer and they also have their own comorbidities, physical problems, and emotional health issues. Yet when they have an older patient with cancer, their loved one, being diagnosed that burden really falls on them. Although if you ask caregivers they don’t call caring for their loved one a burden, they want to help and they want to really make sure that their loved one is getting the care they need. Many times, however, the healthcare professionals neglect the needs of the caregiver.
What we did is we designed a large randomised study which was what we call cluster randomised. The practice sites were randomised across the country. We had 31 practice sites that enrolled patients and caregivers. We were able to enrol 541 patients, these were older patients with cancer who were receiving treatment in the community oncology practices and had one problem on the geriatric assessment. As we know, geriatric assessment is a validated way to capture health and we only enrolled patients who had problems on the geriatric assessment because we wanted to capture a more vulnerable patient population. In addition, the older patients were able to choose one caregiver and we created the definition of caregiver using our patient stakeholder group scoreboard which is led by Beverley Cannon in the United States. They helped us to define caregiver as a person aged 18 and over who was a friend and support person in the delivery of cancer care. So it didn’t have to be someone that we call caregiving in the house, it could be just someone the patient relied on.
The primary aim of the cluster randomised trial was looking at patient outcomes, so communication about age-related concerns, patient satisfaction and patient function and quality of life but we had secondary outcomes where we looked at caregiver satisfaction with communication. We measured communication in a couple of ways; we measured communication by audio recording the clinic visits and really counting up the number of aging related discussions. The intervention was given to the physicians at the sites that were randomised to the intervention and that intervention consisted of a geriatric assessment summary plus recommendations and some of those recommendations included how to communicate with patients and caregivers and also how to support caregivers in what they need.
So we audio recorded the visits and we used that as one of our aims and then we also asked on a survey called the Healthcare Climate Questionnaire about satisfaction. What we’re presenting today is that the geriatric assessment intervention not only increased the number of age-related discussions and the quality of those discussions between physicians, oncologists, patients and caregivers but also increased patient satisfaction with that communication and increased caregiver satisfaction with communication. Caregiver satisfaction, the improvement persisted for three months after the intervention.
So with the geriatric assessment we were able to show that we’re better able to provide patient and caregiver centred care delivery. So rather than not attending to the needs of patients and caregivers, a geriatric assessment allows oncologists to tend to more of their concerns and patients and caregivers end up to be more satisfied with those clinical encounters.
So what’s next?
That’s a great question. I think the geriatric assessment doesn’t do enough for caregivers and even for supportive care. I think we have to start to integrate palliative care models and supportive care models into the geriatric assessment and combine the different disciplines. I also think there should be more dyadic approaches. What dyadic means is partnering patients and caregivers together who receive the intervention together and you’re not just doing things for the patient and hoping the caregiver needs are addressed and the caregiver outcomes are improved but you’re doing things for both the patient and the caregiver at the same time and looking at outcomes over the same time. The reason why I think that is important is because how sick the patient is influences the caregiver because the caregivers really want to help the patients they are caring for and if a caregiver has nutritional problems or depression or a patient has nutritional problems or depression that increases the caregiver depression and distress. So we need to intervene on both the patient and the caregiver at the same time through our care delivery.