Jennifer L Nahum

Abstract

Background: Lymphedema is a progressive and chronic illness. Early detection and treatment often lead to better clinical outcomes and improvement of patients' quality of life. Lymphedema symptoms can assist in detecting lymphedema. However, the use of patient-reported symptom evaluation is still limited in clinical practice. To address this gap in clinical practice, a metropolitan cancer center implemented an electronic patient evaluation of lymphedema symptoms (EPE-LE) to enable patients' real-time symptom report during patients' routine clinical visit while waiting to see their doctors in a waiting room. The purpose of this clinical project was to evaluate the usefulness of EPE-LE during patients' routine clinical visit. Methods: A cross-sectional design was used. Participants were outpatient post-surgical breast cancer patients and clinicians who were involved in the EPE-LE implementation at a metropolitan cancer center of US. Data were collected during the three-month EPE-LE implementation, including patients' report of lymphedema symptoms, patient and clinician satisfaction, and referral to lymphedema specialists. Descriptive statistics were used for data analysis. Results: During the three-month implementation, a total of 334 patients utilized the EPE-LE to report their lymphedema symptoms and 24 referrals to lymphedema specialists. Nearly all of the patients found that the EPE-LE was easy to use (91%) and that they were satisfied with the EPE-LE for reporting lymphedema symptoms (89%). The majority (70%) of patients reported that the EPE-LE helped them to learn about symptoms related to lymphedema and encouraged them to monitor their symptoms. All clinicians (100%) agreed that the use of the EPE-LE improved their lymphedema symptom assessment in post-surgical breast cancer patients; 75% reported that the EPE-LE increased their communication with patients related to lymphedema symptoms, 75% agreed they would recommend the EPE-LE for use at other cancer centers, and 75% reported that the information retrieved from the EPE-LE was helpful in evaluation of lymphedema. Conclusions: The use of EPE-LE enhanced patients' real-time report of lymphedema symptoms, improved patient education on lymphedema symptoms, and helped clinicians for evaluation of lymphedema. The use of EPE-LE is an example how to implement evidence-based research into clinical practice that provides benefits for both patients and clinicians.

Abstract

Objective. To examine the screening practices of family practitioners (FPs) and pediatricians for type 2 diabetes (T2D) in adolescents. Design. Cross-sectional study. Setting and participants. The researchers randomly sampled 700 pediatricians and 700 FPs who participated in direct patient care using the American Medical Association Physician Masterfile using a mail survey. Exclusion criteria included providers who were residents, hospital staff, retirees, or employed by federally owned medical facilities, certified with a subspecialty, or over age 70. Main outcome measures. Providers were given a hypothetical case of an obese, female, teenaged patient with concurrent associated risk factors for T2D (family history of T2D, minority race, signs of insulin resistance) and asked what initial screening tests they would order. Respondents were then informed of the updated American Diabetes Association (ADA) guidelines that added hemoglobin A1c as a screening test to diagnose diabetes. The survey then asked if knowing this change in recommendation has changed or will change their screening practices in adolescents. Main results. 1400 surveys were mailed. After 2 were excluded due to mailing issues, 52% of providers provided responses. Of these, 129 providers reported that they did not care for adolescents (age 10-17), resulting in 604 providers in the final sample, 398 pediatricians and 335 FPs. The vast majority (92%) said they would screen the hypothetical case for diabetes, with most initially ordering a fasting test (fasting plasma glucose or 2-hour glucose tolerance test) (63%) or A1c test (58%). Of the 58% who planned to order HbA1c, only 35% ordered it in combination with a fasting test. HbA1c was significantly more likely to be ordered by pediatricians than by FPs (P = 0.001). After being presented with the new guidelines, 84% said then would now order HbA1c, a 27% increase. Conclusion. In response to information about the new guidelines, providers were more likely to order A1c as part of initial testing. Due to the lower test performance in children and increased cost of the test, the use of HbA1c without fasting tests may result in missed diagnosis of T2D in adolescents as well as increased health care costs.