Pragmatic cluster randomized trial to evaluate effectiveness and implementation of enhanced EHR-facilitated cancer symptom control (E2C2)

Lila J Finney Rutten, Kathryn J Ruddy, Linda L Chlan, Joan M Griffin, Jeph Herrin, Aaron L Leppin, Deirdre R Pachman, Jennifer L Ridgeway, Parvez A Rahman, Curtis B Storlie, Patrick M Wilson, Andrea L Cheville, Lila J Finney Rutten, Kathryn J Ruddy, Linda L Chlan, Joan M Griffin, Jeph Herrin, Aaron L Leppin, Deirdre R Pachman, Jennifer L Ridgeway, Parvez A Rahman, Curtis B Storlie, Patrick M Wilson, Andrea L Cheville

Abstract

Background: The prevalence of inadequate symptom control among cancer patients is quite high despite the availability of definitive care guidelines and accurate and efficient assessment tools.

Methods: We will conduct a hybrid type 2 stepped wedge pragmatic cluster randomized clinical trial to evaluate a guideline-informed enhanced, electronic health record (EHR)-facilitated cancer symptom control (E2C2) care model. Teams of clinicians at five hospitals that care for patients with various cancers will be randomly assigned in steps to the E2C2 intervention. The E2C2 intervention will have two levels of care: level 1 will offer low-touch, automated self-management support for patients reporting moderate sleep disturbance, pain, anxiety, depression, and energy deficit symptoms or limitations in physical function (or both). Level 2 will offer nurse-managed collaborative care for patients reporting more intense (severe) symptoms or functional limitations (or both). By surveying and interviewing clinical staff, we will also evaluate whether the use of a multifaceted, evidence-based implementation strategy to support adoption and use of the E2C2 technologies improves patient and clinical outcomes. Finally, we will conduct a mixed methods evaluation to identify disparities in the adoption and implementation of the E2C2 intervention among elderly and rural-dwelling patients with cancer.

Discussion: The E2C2 intervention offers a pragmatic, scalable approach to delivering guideline-based symptom and function management for cancer patients. Since discrete EHR-imbedded algorithms drive defining aspects of the intervention, the approach can be efficiently disseminated and updated by specifying and modifying these centralized EHR algorithms.

Trial registration: ClinicalTrials.gov, NCT03892967. Registered on 25 March 2019.

Keywords: Electronic health record; Neoplasm; Pain; Palliative care; Patient care team; Patient-reported outcome measure; Quality of life; Self-management; Survivor; Systems integration.

Conflict of interest statement

LJFR, LLC, JMG, JH, ALL, DRP, JLR, PAR, CBS, PMW, and ALC have no competing interests to declare. KJR inherited and then sold (in February 2018) stock in Merck and Co, Inc. and Pfizer, Inc.

Figures

Fig. 1
Fig. 1
Locations of Participating Mayo Clinic Health System Sites in Minnesota and Wisconsin. (Used with permission of Mayo Foundation for Medical Education and Research)
Fig. 2
Fig. 2
Intervention Overview. ePRO indicates electronic patient-reported outcome; E2C2, enhanced, electronic health record–facilitated cancer symptom control; SPADE, sleep disturbance, pain, anxiety, depression, and energy deficit
Fig. 3
Fig. 3
SPIRIT Diagram
Fig. 4
Fig. 4
Stepped Wedge Cluster Design for the Enhanced, Electronic Health Record–Facilitated Cancer Symptom Control (E2C2) Trial
Fig. 5
Fig. 5
Simulated Power in Relation to Effect Size

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