It is highly recommended that depression screening is thoroughly integrated into the treatment of cancer patients. Organizations, such as the American Society of Clinical Oncology, and previous clinical trials have shown that depression screening and subsequent treatment are an important part of effective cancer treatments and improving the quality of life for patients. However, the sheer demand faced by oncologists poses a problem that, unfortunately, places depression screening on the back burner, an unintended negligence.
"Our oncology practices are incredibly busy," noted Erin Hahn, PhD, MPH, a research scientist with the Kaiser Permanente Southern California (KPSC) Department of Research & Evaluation, regarding challenges facing implementation. "And this study was actually before COVID-19, but even then, we had new therapies; we had new treatment pathways; we had explosions of people getting diagnosed with cancer. So, you can imagine having a new program laid on top of everything they were doing-it's hard to adapt to new changes."
Using the developing world of implementation science, Hahn led a trial and team of researchers at KPSC that evaluated six medical centers and their effectiveness in implementing depression screening for breast cancer patients. It is important to note that breast cancer patients were chosen for this study because breast cancer is one of the most commonly diagnosed cancers within KPSC.
To begin, the trial was based at six medical centers spanning across the KPSC extensive health care network and included 1,436 patients who were diagnosed with and received medical consultation for new primary breast cancer between October 1, 2017, and September 30, 2018. These medical centers and the patients they treat were split into two groups: tailored-intervention (three medical centers, 744 patients) and education-only (three medical centers, 692 patients). Both groups were given the same basic education about the depression screening program, and the tailored-intervention sites received additional implementation strategies.
"Part of the reason why depression screening in medical oncology is challenging is that it's actually a multi-component program," Hahn said. "When you think about screening for something, you think of a simple test or a questionnaire and that's it: you did the screening. But what else has to happen is all the downstream work of making sure that the results of the screening are captured and then acted upon appropriately, in a way that best serves the person who received the screening."
In order to best utilize all the resources available through KPSC, patients were presented with a 9-item Patient Health Questionnaire (PHQ-9). Through algorithmic-based scoring, patients were given a score-either low, moderate, or high-and were referred to the service that would best serve them. Patients with lower scores, or mild depression, were given more information about KPSC and resources regarding community behavioral health. Patients scoring moderately were referred to an oncology licensed clinical social worker (LCSW), depression care management, or both. Patients who had scored highly and were viewed to have severe depression were immediately referred to behavioral health services made up of psychologists and psychiatrists, provided with telephone crisis consultation, or both.
In education-only sites, where researchers stepped back from monitoring implementation practice and only educated clinical staff on the program's availability, only three patients were screened for depression. Two of these three patients scored in the low range. The third patient scored in the moderate range. This patient was referred to and successfully completed a visit with a LCSW.
The researchers' approach to implementation at the tailored-intervention sites was much more successful. Using the Consolidated Framework for Implementation Research (CFIR) to guide their study, researchers were able to focus on why this program matters and how they could make it successful. The tailored-intervention program included audit and feedback of performance data, periodic check-ins (called facilitation), and an adaptable clinical workflow.
"CFIR just helps you guide your thinking," Hahn said, before providing examples of this framework. "'Oh, hey, a clinical champion will be really important for this program we are trying to implement.' Or 'What is the local context? Is this something people are really eager to try or is this going to be a harder sell? What kind of materials do we need?' It's super helpful, just to help you think about what kinds of things will make this a success."
This framework and the researchers' more hands-on approach proved to be successful. Of the 744 patients eligible for screening, 596 patients (about 80% of those eligible) were offered PHQ-9 screening during consultation. Eleven percent of the screened patients scored in the moderate or high range, and 94 percent of those receiving these scores received an appropriate referral for the severity in which they scored. The other 6 percent of patients needing immediate referral either declined or were not offered this service. Seventy-five percent of those patients immediately referred to a mental health or behavioral service successfully completed a visit, while the other 25 percent either declined to schedule, cancelled, or failed to attend their appointment.
Although this program failed to screen and refer all 744 patients at the tailor-intervention sites, the results of this study show that implementation is possible and screening is effective. Depression screening during consultation will become a streamlined program across KPSC, including education-only sites. Automated data and feedback generated at tailor-intervention sites will allow researchers to step away from implementation and will guide oncologists in blending this program into daily practice.
"At Kaiser Permanente, we have all these amazing treatment pathways, and there's a lot of work on quality of care," Hahn said. "But sometimes these other facets of the patient's experience get a little bit lost, where people don't always have time to just sit down and say, 'Hey, how are you feeling? Are you doing okay?' And I feel like we really need to pay attention to that."
Elizabeth Rose Galamba is a contributing writer.