The implementation of a physical activity and nutrition protocol into the electronic medical record of adolescent pediatric cancer survivors in a long-term follow-up clinic: sPACE+
Yamamoto, Julienne Ashley
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Between 1975 and 2006, childhood cancer survival rates have increased over 50%, resulting in a much larger population of childhood cancer survivors. As adults, childhood cancer survivors have poorer general health and significantly more health problems which can be linked to toxicities encountered during their treatments. They are more likely to be obese, have endocrine abnormalities, and suffer from hypertension and dyslipidemia. While their leading cause of death 15-plus years after finishing treatment is a second cancer, they also have higher rates of other chronic diseases such as diabetes, insulin resistance, cardiovascular disease, and pulmonary disease. Despite the clear evidence showing poorer health outcomes for childhood cancer survivors, many adolescents do not perceive that they are at increased risk for chronic diseases. Between 2006 and 2008, researchers at the University of Hawaii Cancer Center conducted focus groups that revealed that parents and adolescent survivors lacked knowledge about cancer survivors' increased chronic disease risk, and pediatric oncologists were frustrated with parents' and survivors' unwillingness to modify health risk behaviors and lacked experience with behavior change counseling. Patient-centered Assessment and Counseling for Exercise + Nutrition (PACE+) is a validated, evidence-based physical activity and nutrition intervention that used the Transtheoretical Model to stage patients in varying levels of change. We modified PACE+ materials to make them suitable for adolescent cancer survivors in Hawaii and are calling this modified program Patient-centered Assessment and Counseling for Exercise+ Nutrition for Survivors (sPACE+). Surveys administered to clinicians at the Kapiolani Comprehensive Children's Cancer Center indicated that providers had low levels of consistent physical activity and nutrition counseling, did not take the patient's willingness to change into account when making health behavior recommendations, had several barriers to diet and physical activity counseling, and had low perceived success creating health behavior change with their patients. To address these issues, we modified the original PACE+ program and incorporated it into the EMR by creating a flowsheet and a progress note template. The sPACE+ system is a tool that informs the provider of their patient's physical activity or nutrition status, tells them what to do and what to say, and provides them with written materials relevant to the patient's interests and willingness to change. At the conclusion of this project's usability study, we will administer staff surveys to assess how well the sPACE+ protocol fit into their long-term care delivery system. It is our hope that the sPACE+ system will have great perceived success by the clinic staff and minimal intrusion on their clinic workflow. The implementation of protocols into the EMR is an innovative idea that has shown considerable promise. If EMR-based interventions like sPACE+ are found to be successful, the potential exists for them to be quickly and easily shared between users of the same system at different institutions.
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