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Original article
Factors influencing response enthusiasm to telephone follow-up in patients with oesophageal carcinoma after oesophagectomy Q. GAO,* MD, West China Medical School, Sichuan University, Cheng Du, Sichuan, and Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, L. YUAN,* MD, Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, W.-P. WANG, MD, PHD, Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, H. SHI, MD, Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, & L.-Q. CHEN, MD, PHD, Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China GAO Q., YUAN L., WANG W.-P., SHI H. & CHEN L.-Q. (2014) European Journal of Cancer Care 23, 310–316 Factors influencing response enthusiasm to telephone follow-up in patients with oesophageal carcinoma after oesophagectomy Response enthusiasm to telephone follow-up is a precondition for obtaining exhaustive information; however, no study has yet examined this specific issue. This study aimed to investigate possible factors influencing response enthusiasm to telephone follow-up in patients with oesophageal carcinoma after oesophagectomy and to propose corresponding countermeasures. A telephone follow-up was conducted on patients who underwent oesophagectomy. The possible factors influencing response enthusiasm grades were investigated by univariate and logistic regression analyses. The study enrolled 346 eligible patients. Univariate analysis showed that the tumour, nodes, metastasis (TNM) staging (P = 0.004); survival status (P < 0.001); survival time (P < 0.001); complications/co-morbidities (P = 0.001); and the relationship between the patient and his/her contact person (P < 0.001) were significantly different among the three groups. The first group of patients had high response enthusiasm, the second group had moderate response enthusiasm, and the third group had low response enthusiasm. Logistic regression analysis demonstrated that only the complications/co-morbidities [confidence interval (CI) = −2.310 to −0.665, P < 0.001] and dysphagia status (CI = 0.039–1.509, P = 0.039) were independent factors affecting the response enthusiasm grades. The primary therapeutic results and the current complications and co-morbidities, especially the dysphagia status, were important factors influencing response enthusiasm grades. Planning a follow-up schedule with proper health instructions could be crucial to the quality of follow-up.
Keywords: oesophageal neoplasms, follow-up, response grades.
Correspondence address: Long-Qi Chen, Department of Thoracic Surgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan 610041, China (e-mail: [email protected]). *The first two authors contributed equally to this study. Disclosure: None.
Accepted 15 September 2013 DOI: 10.1111/ecc.12143 European Journal of Cancer Care, 2014, 23, 310–316
© 2014 John Wiley & Sons Ltd
INTRODUCTION Oesophageal cancer is one of the most common malignant diseases worldwide, especially in East Asia and South Africa, where squamous carcinoma is predominant (Hongo et al. 2009; Tettey et al. 2012). The incidence of oesophageal adenocarcinoma has also been rising in western countries in recent decades (Hur et al. 2013).
Factors influencing telephone follow-up
Current therapy regimens rely on combined treatments, which mainly involve surgical treatment and chemotherapy (Cunningham et al. 2006; Stahl et al. 2010). For patients who have undergone oesophagectomy, there is a high incidence of postoperative morbidity and mortality (Raymond 2012). Consequently, communication (or follow-up) between the patient and his or her hospital is necessary to ensure that the patient’s medical needs are addressed. The general role of postoperative follow-up is to improve post-discharge treatment efficacy, and quality of life (Moyes et al. 2010). A long-standing, effective, postoperative follow-up plan can aid in the exploration of further treatment strategies (Nishimura et al. 2012) and increase opportunities for patients to be involved in clinical research, which is of benefit to medical progress (Earle et al. 2003). In our practical experience, once patients are discharged from the hospital, clinicians cannot obtain any information on the patients unless they revisit the hospital and undergo a re-examination. Many oesophageal cancer patients undergo re-examinations at other medical institutions for the sake of convenience. Timely follow-up is helpful for clinicians to know the patient’s status, such as the recurrence of cancer and chemotherapy. If the follow-up schedule is insufficient, then practitioners may lose the opportunity for early detection of cancer relapse. The specific follow-up process could be carried out in several ways, including face-to-face conversations in outpatient clinics, or by electronic mail, follow-up letters and telephone calls. Telephone follow-up is one of the most common methods because it is easily tracked, convenient and swift, and it may reduce the burden on hospitals (Beaver et al. 2009a,b; Kimman et al. 2010a, 2011b). However, because of the lack of face-to-face communication, the quality of telephone follow-up may be easily influenced by the interviewees’ response enthusiasm, which is a precondition for obtaining exhaustive follow-up information. Insufficient follow-up information greatly discounts the value of follow-up. Therefore, it is important to investigate the major variables that influence response enthusiasm to improve the quality of follow-up. Unfortunately, to the best of our knowledge, no published study has yet examined this theme. Kimman and colleagues conducted a series of studies on breast cancer patients to determine optimal follow-up approaches (Kimman et al. 2007a,b, 2010b, 2011a; Benning et al. 2012). Nevertheless, these studies did not investigate response enthusiasm. Therefore, the factors influencing response enthusiasm are still ambiguous, and countermeasures are lacking. © 2014 John Wiley & Sons Ltd
The present research aimed to determine which factors influence response enthusiasm and to propose countermeasures to enhance the quality control of follow-up. METHODS Patient population From January to December 2009, consecutive oesophageal cancer patients identified by biopsy were prospectively enrolled in this study at the Department of Thoracic Surgery, West China Hospital, Sichuan University, Cheng Du, China. One trained interviewer performed most of the telephone follow-ups. Additionally, people proficient in dialects were also invited to participate in interviews occasionally. Variables related to general information and clinical characteristics were recorded. The general information included the patient’s name, gender, age, residence, telephone number of the patient or his/her contact person, and the relationship between the patient and his/her contact person. Patients were grouped by age as follows: (1) >70 years; (2) 61–70 years; (3) 51–60 years; and (4) ≤50 years. Clinical characteristics included the patient’s survival status; survival time; tumour, nodes, metastasis (TNM) staging; postoperative chemotherapy; complications and co-morbidities at the time of follow-up; dysphagia status; and gastroesophageal reflux status. Patients were also grouped by survival time as follows: (1) ≤3 months; (2) >3 months and ≤12 months; (3) >12 months and ≤24 months; and (4) >24 months. Complications and co-morbidities at the time of follow-up were defined according to the Physiological and Operative Severity Score (Copeland et al. 1991). This study further included pneumonia, atelectasis/effusions, chylothorax, adult respiratory distress syndrome, respiratory failure requiring mechanical ventilation, pulmonary embolism, anastomotic leakage, anastomotic stenosis, acid regurgitation and reflux, and severe diarrhoea. Dysphagia status was evaluated by Stoller (Stoller et al. 1977) as follows: (0) no dysphagia on solid diet; (1) dysphagia on solid diet; (2) dysphagia on semisolid diet; (3) dysphagia on fluid diet; and (4) dysphagia with water swallowing. A reflux symptom questionnaire (RSQ) suitable for Chinese patients (Zhang et al. 2007) was used to evaluate gastroesophageal reflux status with the following scale: (0) no reflux in a semisupine position; (1) postprandial reflux in a semisupine position; (2) reflux with empty stomach in a semisupine position; (3) postprandial reflux in an upright position; and (4) reflux with empty stomach in an upright position. 311
GAO ET AL.
The three response enthusiasm grades were defined as follows, and the grades were used to refer to the degree of response enthusiasm: (1) the interviewee answers questions elaborately, even supplying more information than asked on his/her own initiative; (2) the interviewee only answers the questions asked; and (3) the interviewee responds in a frigid manner, or even refuses to answer questions. The time to follow-up complied with The National Comprehensive Cancer Network (NCCN) Guidelines for Esophageal and Esophagogastric Junction Cancers (Ajani et al. 2012). Loss to telephone follow-up was defined when the telephone number was a dead number or the wrong number at the time of the follow-up, or when the interviewer could not reach the patient or his/her contact person after three attempts on different days. The time interval between the two attempts was 2 weeks. Study design The inclusion criteria were as follows: (1) the patient had evidence of biopsy-confirmed oesophageal cancer and (2) was scheduled for oesophagectomy without previous oesophageal cancer-related operations. The exclusion criteria were as follows: (1) the patient was lost to follow-up; (2) was scheduled for oesophagectomy, but refused to undergo the operation; or (3) died during or after the operation in the hospital. The follow-up questionnaire was designed by the research team without disagreements. The enrolled patients were divided into three groups according to their response enthusiasm grades. To control for bias, the study designers did not participate in the follow-up, and data analysis was performed independently by one statistician.
Statistical analysis Measurement data were analysed by one-factor analysis of variance (anova). For ranked data, Kendall’s tau-b was adopted to test for correlations. The ordinal logistic regression model was used for multivariate analysis. Survival analysis was carried out with the life-table method. A difference with P < 0.05 was considered to be statistically significant. All analyses were performed with the Statistical Package for Social Sciences (SPSS), version 13 (SPSS, Chicago, IL, USA). RESULTS Characteristics of patients The present study included 376 patients, 30 (8.0%) of whom were lost to follow-up. There were 296 men and 50 women, and the median age was 60 years. The median survival time was 25.4 months, and the 2-year survival rate was 65%. The relationship between TNM stage and long-term prognosis (i.e. survival status and survival time) was also analysed (Table 1). Univariate analysis of factors influencing response enthusiasm There were 187 patients in the first, 122 patients in second and 37 patients in the third response enthusiasm grade that were included in the analysis. As shown in Table 2, there were differences among the groups in terms of the TNM staging (P = 0.004), survival status (P < 0.001), survival time (P < 0.001), complications/co-morbidities (P = 0.001), and the relationship between the patient and his or her contact person (P < 0.001).
Ethics statement The present study was approved by the Ethics Committee of West China Hospital, Sichuan University. All the work conformed to the provisions of the Declaration of Helsinki.
Multiplicity analysis of influencing factors After all of the parameters had been evaluated, a proportional odds model was designed by setting the response
Table 1. Relationship between TNM stage and long-term prognosis Long-term prognosis Survival status Dead Living Survival time 1 2 3 4
TNM I (n = 34)
TNM II (n = 153)
TNM III (n = 143)
TNM IV (n = 16)
13 (38.2%) 21 (61.8%)
49 (32.0%) 104 (68.0%)
88 (61.5%) 55 (38.5%)
11 (68.8%) 5 (31.3%)
1 (2.9%) 8 (23.5%) 10 (29.4%) 15 (44.1%)
3 (2.0%) 16 (10.5%) 69 (45.1%) 65 (42.5%)
13 (9.1%) 36 (25.2%) 54 (37.8%) 40 (28.0%)
3 (18.8%) 8 (50.0%) 3 (18.8%) 2 (12.5%)
Statistics
P-value
χ2 = 29.999
Original article
Factors influencing response enthusiasm to telephone follow-up in patients with oesophageal carcinoma after oesophagectomy Q. GAO,* MD, West China Medical School, Sichuan University, Cheng Du, Sichuan, and Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, L. YUAN,* MD, Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, W.-P. WANG, MD, PHD, Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, H. SHI, MD, Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, & L.-Q. CHEN, MD, PHD, Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China GAO Q., YUAN L., WANG W.-P., SHI H. & CHEN L.-Q. (2014) European Journal of Cancer Care 23, 310–316 Factors influencing response enthusiasm to telephone follow-up in patients with oesophageal carcinoma after oesophagectomy Response enthusiasm to telephone follow-up is a precondition for obtaining exhaustive information; however, no study has yet examined this specific issue. This study aimed to investigate possible factors influencing response enthusiasm to telephone follow-up in patients with oesophageal carcinoma after oesophagectomy and to propose corresponding countermeasures. A telephone follow-up was conducted on patients who underwent oesophagectomy. The possible factors influencing response enthusiasm grades were investigated by univariate and logistic regression analyses. The study enrolled 346 eligible patients. Univariate analysis showed that the tumour, nodes, metastasis (TNM) staging (P = 0.004); survival status (P < 0.001); survival time (P < 0.001); complications/co-morbidities (P = 0.001); and the relationship between the patient and his/her contact person (P < 0.001) were significantly different among the three groups. The first group of patients had high response enthusiasm, the second group had moderate response enthusiasm, and the third group had low response enthusiasm. Logistic regression analysis demonstrated that only the complications/co-morbidities [confidence interval (CI) = −2.310 to −0.665, P < 0.001] and dysphagia status (CI = 0.039–1.509, P = 0.039) were independent factors affecting the response enthusiasm grades. The primary therapeutic results and the current complications and co-morbidities, especially the dysphagia status, were important factors influencing response enthusiasm grades. Planning a follow-up schedule with proper health instructions could be crucial to the quality of follow-up.
Keywords: oesophageal neoplasms, follow-up, response grades.
Correspondence address: Long-Qi Chen, Department of Thoracic Surgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan 610041, China (e-mail: [email protected]). *The first two authors contributed equally to this study. Disclosure: None.
Accepted 15 September 2013 DOI: 10.1111/ecc.12143 European Journal of Cancer Care, 2014, 23, 310–316
© 2014 John Wiley & Sons Ltd
INTRODUCTION Oesophageal cancer is one of the most common malignant diseases worldwide, especially in East Asia and South Africa, where squamous carcinoma is predominant (Hongo et al. 2009; Tettey et al. 2012). The incidence of oesophageal adenocarcinoma has also been rising in western countries in recent decades (Hur et al. 2013).
Factors influencing telephone follow-up
Current therapy regimens rely on combined treatments, which mainly involve surgical treatment and chemotherapy (Cunningham et al. 2006; Stahl et al. 2010). For patients who have undergone oesophagectomy, there is a high incidence of postoperative morbidity and mortality (Raymond 2012). Consequently, communication (or follow-up) between the patient and his or her hospital is necessary to ensure that the patient’s medical needs are addressed. The general role of postoperative follow-up is to improve post-discharge treatment efficacy, and quality of life (Moyes et al. 2010). A long-standing, effective, postoperative follow-up plan can aid in the exploration of further treatment strategies (Nishimura et al. 2012) and increase opportunities for patients to be involved in clinical research, which is of benefit to medical progress (Earle et al. 2003). In our practical experience, once patients are discharged from the hospital, clinicians cannot obtain any information on the patients unless they revisit the hospital and undergo a re-examination. Many oesophageal cancer patients undergo re-examinations at other medical institutions for the sake of convenience. Timely follow-up is helpful for clinicians to know the patient’s status, such as the recurrence of cancer and chemotherapy. If the follow-up schedule is insufficient, then practitioners may lose the opportunity for early detection of cancer relapse. The specific follow-up process could be carried out in several ways, including face-to-face conversations in outpatient clinics, or by electronic mail, follow-up letters and telephone calls. Telephone follow-up is one of the most common methods because it is easily tracked, convenient and swift, and it may reduce the burden on hospitals (Beaver et al. 2009a,b; Kimman et al. 2010a, 2011b). However, because of the lack of face-to-face communication, the quality of telephone follow-up may be easily influenced by the interviewees’ response enthusiasm, which is a precondition for obtaining exhaustive follow-up information. Insufficient follow-up information greatly discounts the value of follow-up. Therefore, it is important to investigate the major variables that influence response enthusiasm to improve the quality of follow-up. Unfortunately, to the best of our knowledge, no published study has yet examined this theme. Kimman and colleagues conducted a series of studies on breast cancer patients to determine optimal follow-up approaches (Kimman et al. 2007a,b, 2010b, 2011a; Benning et al. 2012). Nevertheless, these studies did not investigate response enthusiasm. Therefore, the factors influencing response enthusiasm are still ambiguous, and countermeasures are lacking. © 2014 John Wiley & Sons Ltd
The present research aimed to determine which factors influence response enthusiasm and to propose countermeasures to enhance the quality control of follow-up. METHODS Patient population From January to December 2009, consecutive oesophageal cancer patients identified by biopsy were prospectively enrolled in this study at the Department of Thoracic Surgery, West China Hospital, Sichuan University, Cheng Du, China. One trained interviewer performed most of the telephone follow-ups. Additionally, people proficient in dialects were also invited to participate in interviews occasionally. Variables related to general information and clinical characteristics were recorded. The general information included the patient’s name, gender, age, residence, telephone number of the patient or his/her contact person, and the relationship between the patient and his/her contact person. Patients were grouped by age as follows: (1) >70 years; (2) 61–70 years; (3) 51–60 years; and (4) ≤50 years. Clinical characteristics included the patient’s survival status; survival time; tumour, nodes, metastasis (TNM) staging; postoperative chemotherapy; complications and co-morbidities at the time of follow-up; dysphagia status; and gastroesophageal reflux status. Patients were also grouped by survival time as follows: (1) ≤3 months; (2) >3 months and ≤12 months; (3) >12 months and ≤24 months; and (4) >24 months. Complications and co-morbidities at the time of follow-up were defined according to the Physiological and Operative Severity Score (Copeland et al. 1991). This study further included pneumonia, atelectasis/effusions, chylothorax, adult respiratory distress syndrome, respiratory failure requiring mechanical ventilation, pulmonary embolism, anastomotic leakage, anastomotic stenosis, acid regurgitation and reflux, and severe diarrhoea. Dysphagia status was evaluated by Stoller (Stoller et al. 1977) as follows: (0) no dysphagia on solid diet; (1) dysphagia on solid diet; (2) dysphagia on semisolid diet; (3) dysphagia on fluid diet; and (4) dysphagia with water swallowing. A reflux symptom questionnaire (RSQ) suitable for Chinese patients (Zhang et al. 2007) was used to evaluate gastroesophageal reflux status with the following scale: (0) no reflux in a semisupine position; (1) postprandial reflux in a semisupine position; (2) reflux with empty stomach in a semisupine position; (3) postprandial reflux in an upright position; and (4) reflux with empty stomach in an upright position. 311
GAO ET AL.
The three response enthusiasm grades were defined as follows, and the grades were used to refer to the degree of response enthusiasm: (1) the interviewee answers questions elaborately, even supplying more information than asked on his/her own initiative; (2) the interviewee only answers the questions asked; and (3) the interviewee responds in a frigid manner, or even refuses to answer questions. The time to follow-up complied with The National Comprehensive Cancer Network (NCCN) Guidelines for Esophageal and Esophagogastric Junction Cancers (Ajani et al. 2012). Loss to telephone follow-up was defined when the telephone number was a dead number or the wrong number at the time of the follow-up, or when the interviewer could not reach the patient or his/her contact person after three attempts on different days. The time interval between the two attempts was 2 weeks. Study design The inclusion criteria were as follows: (1) the patient had evidence of biopsy-confirmed oesophageal cancer and (2) was scheduled for oesophagectomy without previous oesophageal cancer-related operations. The exclusion criteria were as follows: (1) the patient was lost to follow-up; (2) was scheduled for oesophagectomy, but refused to undergo the operation; or (3) died during or after the operation in the hospital. The follow-up questionnaire was designed by the research team without disagreements. The enrolled patients were divided into three groups according to their response enthusiasm grades. To control for bias, the study designers did not participate in the follow-up, and data analysis was performed independently by one statistician.
Statistical analysis Measurement data were analysed by one-factor analysis of variance (anova). For ranked data, Kendall’s tau-b was adopted to test for correlations. The ordinal logistic regression model was used for multivariate analysis. Survival analysis was carried out with the life-table method. A difference with P < 0.05 was considered to be statistically significant. All analyses were performed with the Statistical Package for Social Sciences (SPSS), version 13 (SPSS, Chicago, IL, USA). RESULTS Characteristics of patients The present study included 376 patients, 30 (8.0%) of whom were lost to follow-up. There were 296 men and 50 women, and the median age was 60 years. The median survival time was 25.4 months, and the 2-year survival rate was 65%. The relationship between TNM stage and long-term prognosis (i.e. survival status and survival time) was also analysed (Table 1). Univariate analysis of factors influencing response enthusiasm There were 187 patients in the first, 122 patients in second and 37 patients in the third response enthusiasm grade that were included in the analysis. As shown in Table 2, there were differences among the groups in terms of the TNM staging (P = 0.004), survival status (P < 0.001), survival time (P < 0.001), complications/co-morbidities (P = 0.001), and the relationship between the patient and his or her contact person (P < 0.001).
Ethics statement The present study was approved by the Ethics Committee of West China Hospital, Sichuan University. All the work conformed to the provisions of the Declaration of Helsinki.
Multiplicity analysis of influencing factors After all of the parameters had been evaluated, a proportional odds model was designed by setting the response
Table 1. Relationship between TNM stage and long-term prognosis Long-term prognosis Survival status Dead Living Survival time 1 2 3 4
TNM I (n = 34)
TNM II (n = 153)
TNM III (n = 143)
TNM IV (n = 16)
13 (38.2%) 21 (61.8%)
49 (32.0%) 104 (68.0%)
88 (61.5%) 55 (38.5%)
11 (68.8%) 5 (31.3%)
1 (2.9%) 8 (23.5%) 10 (29.4%) 15 (44.1%)
3 (2.0%) 16 (10.5%) 69 (45.1%) 65 (42.5%)
13 (9.1%) 36 (25.2%) 54 (37.8%) 40 (28.0%)
3 (18.8%) 8 (50.0%) 3 (18.8%) 2 (12.5%)
Statistics
P-value
χ2 = 29.999
