Benefits and Challenges in Use of a Standardized Symptom Assessment Instrument in Hospice

Abstract

Background: Hospices are now mandated to perform routine quality assessment under the final Medicare Hospice Conditions of Participation, creating an opportunity to explore standardized approaches to monitoring hospice quality. Objective: We report hospice staff experiences using a standardized symptom assessment instrument, the Edmonton Symptom Assessment System (ESAS), in a pilot study designed to develop and test quality measures on symptom management. Use of the ESAS illustrates the benefits and challenges arising with standardized symptom assessment for quality monitoring in hospice. Methods: We interviewed 24 individuals representing 8 hospices involved with the National Association for Home Care & Hospice Quality Assessment Collaborative, which pilot tested the ESAS as a source of standardized data for quality assessment. Transcripts were analyzed using the constant comparative method. Results: Participants reported benefits and challenges with the ESAS. Benefits were that the ESAS was a brief and easy tool that identified areas of concern, engaged patients in symptom assessment, and monitored symptom changes over time. Additionally, the ESAS was viewed as a useful teaching tool for less experienced staff. Challenges included lack of clarity about inclusion rules and frequency of assessments; difficulty interpreting the numeric symptom rating scale, difficulty incorporating patient preferences with symptoms, and a sense that the use of standard assessment instruments was ''unnatural.'' Discussion: Recommendations to promote effective use of ESAS data for quality monitoring of hospice care include standardizing implementation procedures, adding patients' preferences to the ESAS form, and staff education to enhance comfort with the instrument before implementation.

Health care providers’ use and knowledge of the Edmonton Symptom Assessment System (ESAS): is there a need to improve information and training?

“…Previously reported concerns from HCPs have focused on four key areas: (a) clinical relevancy [28], (b) misunderstandings regarding appropriate use [15,29], (c) misinterpretation of high symptom ratings as poor quality of care [15], and (d) attitudinal barriers [15,28]. Some HCPs have suggested that the tool lacks clinical relevancy if other team members do not refer to the tool when deciding about treatment options [28].…”

“…Some HCPs have suggested that the tool lacks clinical relevancy if other team members do not refer to the tool when deciding about treatment options [28]. Others have highlighted concerns regarding the lack of understanding regarding the tool's use, particularly with respect to frequency of assessments and the misinterpretation of numerical rating scales [15,29]. In one study [15], participants reported concerns about high symptom ratings being interpreted as poor quality of care.…”

“…Others have highlighted concerns regarding the lack of understanding regarding the tool's use, particularly with respect to frequency of assessments and the misinterpretation of numerical rating scales [15,29]. In one study [15], participants reported concerns about high symptom ratings being interpreted as poor quality of care. They did not, however, consider other possible explanations for these high ratings, such as expected changes associated with advancing disease or patient preferences.…”

“…In some cases, patients may rate their symptoms high, yet also view this as being a preferred or acceptable level of symptom control [25]. Attitudinal issues included viewing routine assessments as "unnatural" or burdensome for patients [15,28], or preferences to use one's own symptom assessments [29]. These concerns reinforce the need for targeted knowledge translation activities and educational programs for staff to enhance the uptake and ensure the appropriate use of the ESAS in clinical practice [28].…”

“…Different versions of the ESAS have been used in research studies [9][10][11][12]. Recent studies have indicated that patients may have difficulty understanding the terminology and correct use of the ESAS [9,[13][14][15]. Additionally, numerous studies have demonstrated the lack of agreement between HCP assessment of symptoms and patient self-report [13,[16][17][18][19].…”