The Edmonton Symptom Assessment System 25 Years Later: Past, Present, and Future Developments

Abstract

Context: Routine symptom assessment represents the cornerstone of symptom management. Edmonton Symptom Assessment System (ESAS) is one of the first quantitative symptom assessment batteries that allows for simple and rapid documentation of multiple patient-reported symptoms at the same time.

Objectives: To discuss the historical development of ESAS, its current uses in different settings, and future developments.

Methods: Narrative review.

Results: Since its development in 1991, ESAS has been psychometrically validated and translated into over 20 languages. We will discuss the variations, advantages, and limitations with ESAS. From the clinical perspective, ESAS is now commonly used for symptom screening and longitudinal monitoring in patients seen by palliative care, oncology, nephrology, and other disciplines in both inpatient and outpatient settings. From the research perspective, ESAS has offered important insights into the nature of symptom trajectory, symptom clusters, and symptom modulators. Furthermore, multiple clinical studies have incorporated ESAS as a study outcome and documented the impact of various interventions on symptom burden. On the horizon, multiple groups are actively investigating further refinements to ESAS, such as incorporating it in electronic health records, using ESAS as a trigger for palliative care referral, and coupling ESAS with personalized symptom goals to optimize symptom response assessment.

Conclusion: ESAS has evolved over the past 25 years to become an important symptom assessment instrument in both clinical practice and research. Future efforts are needed to standardize this tool and explore its full potential to support symptom management.

Keywords: Clinical trial; dyspnea; fatigue; neoplasms; pain; palliative care; personalized medicine; surveys and questionnaires; symptom assessment.

Conflict of interest statement

Conflict of interest: None reported

Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1. Edmonton Symptom Assessment Scale

The current version used at MD Anderson Cancer Center uses 24 hour as the time frame anchor for the 0–10 numeric rating scales.

Figure 2. Use of ESAS to Trigger Palliative Care Referral

Routine symptom assessment needs to be endorsed by clinicians and coupled with action plans to improve clinical outcomes. A recent international consensus identified severe symptom distress as a criteria for palliative care referral, although this threshold may need to be refined at each institution.(128)

Figure 3. ESAS Displays

ESAS can be graphically displayed, and the pattern of symptom expression can be highly informative. (A) Globally elevated symptom expression – this pattern may suggest the presence of symptom modulators such as depression or anxiety. These modulators would need to be properly addressed as part of the symptom management plan. (B) U-shape distribution – some patients may under-report their level of anxiety and depression even though they may be contributing to their high physical symptom expression. These patients may benefit from assessment of their emotional status even if they do not report any. (C) Solitary pain – some patients have very high pain expression but no other associated symptoms which is atypical. The clinician may want to carefully characterize the patient’s pain history and ensure safe opioid use. (D) ESAS symptom expression array – each column represents one ESAS assessment for an individual patient, each row represents one ESAS symptom, and the colour represents symptom intensity (green = none, red = worst). This novel display may be generated by a computer program to illustrate the ESAS symptoms for multiple patients at the same time, or for the same patient over time. The example here displays ESAS scores on admission for patients at an acute palliative care unit. Symptoms cluster can be clearly detected (fatigue, appetite, drowsiness). Nausea had low expression. The expression of dyspnea was also associated with anxiety.

Figure 4. Symptom Response Criteria

(A) Distribution of Personalized Symptom Goal for 10 Symptoms. A majority of patients reported a personalized symptom goal of 3 or less. (B) Response Rates Differences by Baseline Symptom Intensity and Response Criteria. We plotted the response rates by two criteria (minimal clinically important difference [MCID] and personalized symptom goal [PSG]) according to baseline symptom intensity (i.e. mild 1–3, moderate 4–6, and severe 7–10). Using the MCID criteria, patients with higher baseline symptom intensity were more likely to achieve a response and vice versa; in contrast, the personalized symptom response criteria resulted in the opposite conclusion. P-values were computed based on the McNemer test (* P