Many transplant recipients may experience physical and emotional symptoms, such as anxiety, fatigue, sleep problems, pain, etc. Often, these symptoms are not reported or managed well, and can affect a patient's quality-of-life. Transplant recipients are grateful for the "gift of life" but physical and emotional symptoms reduce their quality-of-life. Transplant recipients and caregivers have felt unprepared for the ongoing symptoms and reduced quality-of-life post-transplant. One way of monitoring and managing these symptoms is using the Emotion And Symptom-focused Engagement (EASE) intervention. EASE was originally developed for patients with acute leukemia and has begun to be adapted to help monitor and manage physical and emotional symptoms for organ transplant recipients. EASE is comprised of two components: 1. Psychological - 8 supportive counselling sessions delivered by mental health clinicians to address concerns about mental health, losses from organ failure, coping with a transplant, experiences with living on the brink of death for a prolonged period of time, etc. 2. Physical - Regular assessments of physical symptoms using questionnaires and referral to healthcare professionals for symptom management as necessary. EASE uses questionnaires, also called patient reported outcome measures (PROMs), for symptom assessment and monitoring. PROMs measure symptom severity, similarly to how bloodwork measures organ functioning. PROMs, as part of EASE, will ask recipients questions and help identify relevant physical, emotional, and social symptoms to enhance their care. With the help of specialists, patients, and support from the Kidney Foundation of Canada, our team has begun to adapt the EASE intervention for transplant recipients. In order to finalize the adaptation of the EASE intervention for use in a routine transplant clinic, we are launching a pre-pilot study to gain real-life experience from managing symptoms of SOT recipients with the use of EASE-SOT.
This is a parallel arm, randomized, controlled pilot study that will assess the feasibility for a large effectiveness trial using the EASE intervention to screen and manage emotional distress and physical symptoms among solid organ transplant (SOT) recipients. We will use a sequential cluster organization for recruitment. Initially, we will recruit kidney and kidney-pancreas transplant recipients, since we already have funding for this portion of our work. Subsequently, we will complete our study plan by recruiting liver, lung, and heart transplant recipients. EASE integrates supportive counseling and trauma-focused cognitive behavioral therapy (CBT) (EASE-psy) with systematic physical symptom screening and triggered referral to supportive care to manage moderate to severe physical symptoms (EASE-phys). Participants in the intervention group receive EASE plus usual care. Each participant will participate in 8 EASE-psy sessions, starting twice a week during the inpatient stay and once every 1-2 week thereafter. They will also be screened for physical symptoms using electronic patient-reported outcome measures (ePROMs) twice a week while in-patient and once a week during the rest of the 8-week intervention period (EASE-phys). Based on individual preference, participants will receive these ePROMs either on tablets or their personal electronic devices via email, while in the hospital ward or in clinics, ensuring easy access and administration of these tools. Participants will receive an output report that provides graphic representation of their current and previous scores on the various domains of health (e.g., depression, fatigue, etc.). This report will contain customized embedded URL links to the Symptomcare public domain. Embedded links will be in the form of: https://symptomcare.org/managing-my-symptoms-overview-patient/depression/?subjectid=1234\&token=abcd. If scoring above threshold for any symptom assessed during routine screening, participants will be referred/re-referred to a "symptom control" team. Participants in the control group receive usual care alone. Additional ePROMs will be completed at baseline, 4, 8 12 and 20 weeks by patients in both arms.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
SUPPORTIVE_CARE
Masking
NONE
Enrollment
120
EASE integrates supportive counseling and trauma-focused cognitive behavioral therapy (CBT) (EASE-psy) with systematic physical symptom screening and triggered referral to supportive care to manage moderate to severe physical symptoms (EASE-phys) using electronic patient reported outcome measures (ePROMs). The intervention duration is 8 weeks. Based on individual preference, EASE-psy may be administered in person or virtually via Microsoft Teams. Based on individual preference, participants may receive ePROMs either on tablets or to their personal electronic devices via email, while at the hospital ward and in clinics, ensuring easy access and administration of these tools.
Toronto General Hospital
Toronto, Ontario, Canada
Recruitment Target
Feasibility of the EASE-SOT intervention will be confirmed if our recruitment target of 120 participants (40 kidney and kidney-pancreas transplant recipients and 80 liver, lung, and heart transplant recipients) in a 30 month recruitment period is met.
Time frame: Baseline
Consent Rate
The consent rate describes the proportion of eligible patients who decline consent. Feasibility of the EASE-SOT intervention will be confirmed if the decline rate is ≤50%.
Time frame: Baseline
Retention Rate
The proportion of enrolled participants who continue to participate in the study at 8 weeks post-enrollment. Feasibility will be confirmed by a retention rate of 70%.
Time frame: Baseline to week 8 (8 weeks)
Adherence Rate
The proportion of enrolled participants who complete the EASE-Psy sessions, the symptom screening (EASE-phys) and outcome measures at the time offered, and have meetings the supportive care team if indicated by screens. Feasibility will be confirmed if ≥50% of participants complete EASE-psy sessions and symptom screening (EASE-phys) and outcome measures ≥50% of the time offered and have ≥1 meeting with the supportive care team if indicated by screens.
Time frame: Baseline to week 20 (20 weeks)
Drop-out Rate
The drop-out rate describes the proportion of enrolled participants who drop-out of the study for any reason (modality change, death, withdrawal, or loss to follow-up, etc.). Reasons for drop-out will be documented to assess the feasibility of the EASE-SOT intervention.
Time frame: Baseline to week 20 (20 weeks)
Patient Acceptability
Proportion of patients who find the EASE-SOT intervention 1) acceptable, 2) not burdensome, and 3) important based on responses to the "Patient Satisfaction Survey". Acceptability will be confirmed if \>80% of patients find EASE acceptable.
Time frame: Baseline to week 20 (20 weeks)
Clinical Team Acceptability
Proportion of staff who find the EASE-SOT intervention intrusive to workflow, based on responses to the "Staff Satisfaction Survey". Acceptability will be confirmed if \<20% of staff find the process intrusive to workflow.
Time frame: Baseline to week 20 (20 weeks)
Incidence Rate of Healthcare Use
11-item recent healthcare use questions regarding healthcare use events such as recent hospitalizations, emergency visits, healthcare use. Incidence rates (event/100 patient years) of hospitalization, emergency admission, and hospitalization. Incidence rates will be compared between the two groups.
Time frame: Baseline to week 20 (20 weeks)
Post-transplant Quality of Life using the EQ-5D-5L
Measured by the the EuroQol-5 Dimension-5 Level (EQ5D5L) and Patient Reported Outcomes Measurement Information System (PROMIS) physical and mental health summary scores. The EQ5D5L measures quality of life (QOL) and utilities of health states by assessing mobility, self-care, usual activities, pain/discomfort, and anxiety/depression using a single item for each domain, measured on five response levels. We will use the Canadian value set. The PROMIS physical and mental health summary scores are calculated using responses to the domain specific item banks included in the PROMIS 29+2 v2.1 Profile measure.
Time frame: Baseline to week 20 (20 weeks)
Post-transplant Quality of Life using PROMIS physical and mental health summary scores
The Patient Reported Outcome Measurement Information System (PROMIS) 29+2 v1.2 profile assesses pain intensity using a single 0-10 numeric rating item, cognitive function using 2 items, and seven additional domains of health (physical function, fatigue, pain interference, depression, anxiety, ability to participate in social roles and activities, and sleep disturbance). The seven additional domains of health will be assessed using computer adaptive testing (CAT). The PROMIS 29 scales are scored on a T-score metric with a mean score of 50 and standard deviation of 10. For symptom domains, a higher score indicates a higher severity of that symptom. For function domains, a higher score indicates less impairment. The PROMIS physical and mental health summary scores are calculated using responses to the domain specific item banks included in the PROMIS 29+2 v2.1 Profile measure.
Time frame: Baseline to week 20 (20 weeks)
Presence of post-traumatic stress symptoms post-transplant using the SASRQ
Measured by the Stanford Acute Stress Reaction Questionnaire (SASRQ). The SASRQ is a 30-item questionnaire used to measure traumatic stress symptoms, including anxiety and dissociation symptoms, using a valid and reliable scale. The instructions were modified to refer to organ failure and the transplant surgery as the "traumatic event".
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Time frame: Baseline to week 20 (20 weeks)
Presence of post-traumatic stress symptoms post-transplant using the PCL-5
Measured by the Post-traumatic stress disorder checklist (PCL-5). The PCL-5 is a 20-item questionnaire used to measure traumatic stress using a valid and reliable scale. The self-report rating scale is 0-4 for each symptom, reflecting a change from 1-5 in the Diagnostic and Statistical Manual - IV (DSM-IV).
Time frame: Baseline to week 20 (20 weeks)
Severity of physical and emotional symptoms post-transplant
Measured by Patient Reported Outcomes Measurement Information System item banks administered using Computer Adaptive Testing (CAT) for anxiety, depression, dyspnea severity, fatigue, sleep disturbance, pain interference, pain intensity, physical function, cognitive function, and ability to participate in social roles and activities. For each domain specific item bank, responses to individual items are summed and converted into a standardized T-score, normalized to the US general population with a mean score of 50 and standard deviation of 10. For symptom domains, a higher score indicates a higher severity of that symptom. For function domains, a higher score indicates less impairment. When administered as CATs, 4 or more items are administered until standard error of measurement (SEM) is 0.30 or lower (equivalent to a reliability of 0.9 or higher) or 6 items have been asked. The recommended cut-off score for moderate-severe anxiety and depression symptoms on PROMIS tools is ≥60.
Time frame: Baseline to week 20 (20 weeks)