January 2007

Dear Readers Here's the Article for this Month:

Errors in symptom intensity self-assessment by patients receiving outpatient palliative care

Author(s): Garyali A, Palmer JL, Yennurajalingam S, Zhang T, Pace EA, Bruera E.

Journal: Journal of Palliative Medicine 2006; Vol. 9, No. 5: 1059-1065
(ESAS)

The Edmonton Symptom Assessment Scale (ESAS) is a reliable and valid tool developed to assess the daily symptoms of palliative care patients. ESAS considers the presence and severity of ten common symptoms experienced by cancer patients: pain, fatigue, nausea, depression, anxiety, drowsiness, shortness of breath, appetite, sleep, and well-being. The ESAS score can range from 0 (absence of a symptom) to 10 (worst symptom imaginable).

The authors carried out a study to evaluate if patients misinterpret questions when responding to items on the ESAS. The charts of 60 consecutive out-patients were reviewed. After a patient completed the ESAS, the same physician immediately interviewed each patient in order to determine if they had scored the symptom properly. All patients were asked to revise their symptom score after the physician interview if the score was deemed to be erroneously reported.

A weighted K statistic was used to determine agreement between the assessments by the patients before and after talking with the physician. Agreement was defined as absent (0), mild (1-3), moderate (4-7) or severe (8-10). The screening performance of the ESAS for mild or moderate symptom assessment was determined by calculating the sensitivity, specificity, and accuracy of the patients’ initial assessments. Forty-four percent of patients scored 263 symptoms in agreement, 131 symptoms were revised downward (24%) and 146 were revised upward (27%).

Complete agreement ranged from 58% for sleep to 82% for well-being. The weighted K for agreement ranged from 0.49 for drowsiness (the highest level of disagreement) to 0.78 for well-being. Dyspnea, nausea, anxiety and depression were symptoms that had more agreement, whereas there was less agreement for symptoms such as lack of sleep and lack of appetite.

The screening performance of the patient self-assessment ESAS for symptom intensity was less sensitive for nausea and drowsiness if the intensity was mild. It was less sensitive for pain, nausea, anxiety and drowsiness if the symptom intensity was moderate. The screening performance of the initial assessment for symptom intensity of moderate, or greater, showed a sensitivity of 100% for dyspnea, but was lower than 80% for pain, nausea, anxiety, and drowsiness. The specificity was also low for sleep, and low, but improved, for fatigue and appetite.

Why I chose this article

In the palliative care setting, the regular assessment of the intensity of physical and emotional symptoms is necessary for appropriate symptom management.

This study shows that the patients’ self-assessment of symptoms using a validated tool such as the ESAS may be erroneous if doctors and nurses do not routinely check the way patients have completed the assessment form.

These results show that during the validation process of assessment tools the number of errors of omission made by the patients while filling in the questionnaire should be collected and considered.

These results remind us that the time we spend communicating with our patients is very important not only for accurate symptom assessment but for planning effective palliation.

Regards,

Carla Ripamonti, MD
Member of the Board of Directors, IAHPC

Please visit the following link to read past Articles Of The Month:
http://www.hospicecare.com/AOM/

Please visit the following link to read past Articles Of The Month:
http://www.hospicecare.com/AOM/