Clinician documentation of social circumstances of older and younger women receiving chemotherapy for early breast cancer.

Background: The Institute of Medicine (IOM) recommends that essential aspects of a patient's sociodemographic, psychological and behavioral characteristics be documented in the electronic health record (EMR).

Patients and methods: For this study of women receiving chemotherapy for early breast cancer (Stage I-III), EMR clinician notes were queried with regard to documentation of the patient's current (1) living situation, (2) caregiver responsibilities, and (3) accompaniment during chemotherapy. Descriptive statistics for patient sociodemographic and tumor characteristics, and clinician-reported social circumstances were reported for older and younger patients and compared between two age groups using Fisher's exact tests for categorical variables and t-tests for continuous variables.

Results: The sample includes 104 women aged 65 or older (range 65-83) (17% Black) and 250 under age 65 (range 23-64) (22% Black). Mean number of comorbidities was 3.7 (range 0-8) among older patients and 1.7 (range 0-9) among younger patients (p<.0001). There were no significant inter-group differences in breast cancer stage or phenotype. Clinician notes affirmatively documented that the patient was living with someone (70% older/85% younger) (p=.002), the patient had caregiver responsibilities (12% older/44% younger) (p<.0001) and was accompanied by someone during chemotherapy (79% older/89% younger) (p=.02).

Conclusion: Clinician notes pertaining to younger patients as compared to older patients more often provided affirmative and specific documentation that the patient was living with someone, a caregiver for someone, and accompanied by someone during the chemotherapy infusion visit. These three factors are important to document and monitor in patients of all ages as they can impact treatment experience and quality of life during and after chemotherapy.