Development of a tailored survey to evaluate a patient-centered initiative

OBJECTIVES

Patient-centered care initiatives have proliferated, but assessing their effectiveness requires measures tailored to their likely effects. In this article, we describe the development and pilot testing of patient surveys used to assess change in patients' cancer care experiences over time in response to a patient-centered care initiative.

STUDY DESIGN

Prospective case series.

METHODS

Domains of patient-centered care were informed by the goals of the initiative and a review of existing tools. Items were selected and modified from 6 domains of validated or semivalidated instruments. Items were piloted with patients with cancer in waiting room settings to further assess the relevance and clarity of items, whether important concepts were missing, and acceptability regarding place and timing of the surveys and to estimate baseline top box scores (percentage of patients scoring an item the highest quality level) to minimize likely ceiling effects. The instrument was then administered to a consecutive sample of Stanford Cancer Center patients. Baseline item responses, Cronbach's alpha, and response bias were estimated.

RESULTS

Items were modified based on patient feedback, top box scores, and reassessment of the domains. Over 6 months, 11,273 patients were surveyed, with a 49.7% response rate. Baseline top box scores ranged from 41.7% to 75.0% for any given item. Reliability and internal consistency were high for all domains (Cronbach's alpha ≥0.80) except for the access domain.

CONCLUSIONS

We developed reliable instruments to evaluate the essential elements of a patient-centered care initiative at an academic medical center, which minimized patient burden and maximized the response rate.

[Observational study of outpatient unit duration of stay depending on the route of administration (intravenous vs subcutaneous) for a targeted therapy]

New routes of administration available for some targeted therapies, especially subcutaneous injections, have an impact not only on the patients' daycare experience, but also on the unit's organization. This observational study conducted on 48 voluntary patients at the Institut universitaire du cancer Toulouse-Oncopole shows that the mean duration of the outpatient unit stay is diminished by one hour when a subcutaneous injection is used instead of an intravenous route. This duration decrease is mainly caused by an 82% average reduction in treatment duration. However, the waiting times before and after the treatment itself are not significantly impacted. Organizational methods related to the treatment prescription and preparation remain indeed the same. Anticipated prescription is not noticeably impacted either. This reduction of the duration of stay will truly be obtained if the whole unit's organization is adapted.

Are we prepared to implement a Lean philosophy within cancer-care service in Oman?

Lean, as it applies to business, has come to signify simplicity, swift response, and efficiency. The concept is to do more with less; namely, to use resources in the most productive way possible through the elimination of all types of waste. The Lean approach can be applied to any field, including healthcare, in which the exponential growth of costs is widespread. Hospitals began experimenting with Lean healthcare in 1990s. Equal accessibility to healthcare is consistent with the tenets of social justice and a society’s duty to ensure basic healthcare to everyone. However, the gap between a state’s constitutional responsibility and resource availability is widening, creating a need for an evolution in healthcare provision based on relevance, objectivity, and impartiality. Health-services providers must juggle limited resources to ensure even-handed healthcare availability to all in the era of cost explosion.

Biobanks and Comprehensive Cancer Center Finland (FICAN) as institutions enabling clinical drug testing

Clinical trials aiming at developing targeted drug therapies require the identification of appropriate patient groups, utilizing both clinical information and the biological profile of the disease. The Finnish healthcare system provides exceptional possibilities for utilizing health data in identifying patient groups, planning of clinical sample studies and recruiting patients. Biobanks established at university hospitals together with the regional cancer centers play a central role in collecting biological specimens and attaching health data to the specimens. Combined with longitudinal health data, the collections of tissue specimens obtained in connection with the diagnosis offer versatile possibilities for the development of companion diagnostics of targeted drugs. Specimens collected on the basis of informed consent in connection with diagnosis and treatment enable the identification of patients suitable for drug trials, and a contact according to the consent. In the development of new functions, national collaboration - both geographical and between research infrastuctures - becomes of paramount importance. Combining the resources of biobanks, the genome strategy and the Comprehensive Cancer Center, an enabling legislation and, above all, patients with a positive attitude towards examinations, offer excellent possibilities for Finland to become the model country of individualized treatment.

[Sarcoma centres : a necessary tool in the management of patients and for research.]

Sarcomas are rare diseases, the treatment of which requires an appropriate technical plateform and a broad spectrum of multidisciplinary specialists. Many are initially treated by unplanned excision, and then referred to specialized centres. Secondary treatments may lead to higher complication rates and local recurrence, with lower functional outcome, life quality and possibly overall survival. In order to improve the accessibility for referral to a specialist centre, the coordination of clinical and research activities, and the quality of the management of sarcomas in general, Lausanne University Hospital (CHUV) has opened a Sarcoma centre on October 1st 2016. The objective of the present paper is to illustrate the concept and provide useful clinical recommendations.

Quality assessments for cancer centers in the European Union

BACKGROUND

Cancer centers are pressured to deliver high-quality services that can be measured and improved, which has led to an increase of assessments in many countries. A critical area of quality improvement is to improve patient outcome. An overview of existing assessments can help stakeholders (e.g., healthcare professionals, managers and policy makers) improve the quality of cancer research and care and lead to patient benefits. This paper presents key aspects of assessments undertaken by European cancer centers, such as: are assessments mandatory or voluntary? Do they focus on evaluating research, care or both? And are they international or national?

METHODS

A survey was sent to 33 cancer centers in 28 European Union member states. Participants were asked to score the specifics for each assessment that they listed.

RESULTS

Based on the responses from 19 cancer centers from 18 member states, we found 109 assessments. The numbers have steadily increased from 1990's till 2015. Although, a majority of assessments are on patient-care aspects (n = 45), it is unclear how many of those include assessing patient benefits. Only few assessments cover basic research. There is an increasing trend towards mixed assessments (i.e., combining research and patient-care aspects)

CONCLUSIONS

The need for assessments in cancer centers is increasing. To improve efforts in the quality of research and patient care and to prevent new assessments that "reinvent the wheel", it is advised to start comparative research into the assessments that are likely to bring patient benefits and improve patient outcome. Do assessments provide consistent and reliable information that create added value for all key stakeholders?

The business of palliative medicine—Part 3: The development of a palliative medicine program in an academic medical center

Palliative medicine is the total continuing care of patients with cancer. Most resources for cancer care focus on curative attempts while often ignoring the symptoms created by the disease and its treatment. Attempts at curative treatment of the malignancy must be coupled with pain and symptom relief, psychosocial and spiritual care, and support for the patient and family extending from the time of diagnosis through the bereavement period. To accomplish this important goal, we must establish comprehensive palliative medicine programs in cancer centers throughout the world. These programs must include education, research, and patient care and must work through an interdisciplinary team. The Cleveland Clinic Foundation palliative medicine program (PMP) is composed of a primary inpatient service, consult service, outpatient clinic, hospice homecare, and cancer homecare services. In this article, we describe the structure and development of the program and suggest future avenues for growth.

Procedural Impact of a Dedicated Interventional Oncology Service Line in a National Cancer Institute Comprehensive Cancer Center

PURPOSE

We tested the hypothesis that establishing a dedicated interventional oncology (IO) clinical service line would increase clinic visits and procedural volumes at a single quaternary care academic medical center.

METHODS

Two time periods were defined: July 2012 to June 2013 (pre-IO clinic) and July 2013 to June 2014 (first year of dedicated IO service). Staff was recruited, and clinic space was provided in the institution's comprehensive cancer center. Clinic visits and procedure numbers were documented using the institution's electronic medical record and billing forms. IO procedures included were transarterial chemoembolization, Y-90 radioembolization, perfusion mapping for Y-90, portal vein embolization, and bland embolization. We compared changes in clinic visit and procedure numbers using paired t tests. Changes after IO initiation were compared to 1-year changes in the Medicare 5% Limited Data Set by cross-referencing Current Procedure Terminology and International Classification of Diseases codes in 2012 and 2013.

RESULTS

Clinic visits increased from 9 to 204 (P = .003, t = 8.89, df = 3). Procedures increased from 60 to 239 (P = .018, t = 3.85, df = 4). Procedural volumes increased at least 150% for each subtype. The volumes in the 5% Limited Data Set did not change significantly over the 2-year period (443 to 385, P > .05).

CONCLUSIONS

The establishment of a dedicated IO service significantly increased clinic visits and procedural volumes. National trends were unchanged, suggesting that the impact of our program was not part of a sudden increase of IO procedures.

Insights From Building a New National Cancer Institute Community Oncology Research Program Site

BACKGROUND

The new National Cancer Institute (NCI) Community Oncology Research Program (NCORP) went live August 1, 2014; 34 sites were selected for the program, including 7 new sites that previously did not have a research grant from the NCI. This report describes the first year of a new program site.

METHODS

Accrual, investigator and site participation, and number of open studies by the program over the first 12 months of the grant were compared to performance at our institution over the prior 12 months.

RESULTS

During the pre-NCORP period, 84 patients were accrued to NCI-sponsored trials and 106 patients to non–NCI-sponsored trials. In year 1 of the new program, 140 were accrued to NCI-sponsored trials—a 66% improvement, and 109 patients to non–NCI-sponsored trials (P = 0.013 when comparing corresponding increases for NCI vs non-NCI trials). Success of the NCI-sponsored trials was associated with increased accrual to both treatment trials (P = 0.03) and Alliance for Clinical Trials in Oncology-sponsored trials (P = 0.0001).

CONCLUSIONS

NCORP implementation was associated with a significant (P = 0.013) improvement in accrual to NCI-sponsored trials that was immediate (1 year) and large (a 66% increase in accrual). In year 2, the intention is to increase cancer control studies; foster inclusion of radiation, surgical, gynecologic, and neurologic oncologists; and focus on minority outreach. Studies that accrue poorly will be assessed, and those accruing poorly on a national basis will be considered for closure. Studies accruing well nationally will be evaluated for barriers to local accrual.

A pilot videoconference group stress management program in cancer survivors: lessons learned

CONTEXT

Cancer is a challenging experience and there is evidence that psychosocial interventions are effective at improving adjustment following treatment. At our cancer center, 14 cancer survivors (breast, prostate and blood cancers) completed a four-session cognitive-behavioral stress program. The first session was delivered at the survivor's local cancer center, where they were provided with a loaner tablet. The three subsequent sessions were delivered through group-based videoconference on the tablet. Session content was supplemented with a tailored ebook, designed specifically for this program. Participants provided feedback about the program as well as a standardized measure of perceived stress.

ISSUES

Despite evidence that psychosocial programs are effective, there are significant barriers to dissemination, particularly for those residing in rural areas who do not live near academic medical centers where such programming is more readily available. Our experiences delivering a group-based videoconference program in cancer survivors are described, including positives and challenges associated with its design and implementation.

LESSONS LEARNED

Study participants enrolled from across four different US states, and the majority reported at least a 30-minute commute to their cancer center. This travel burden played a meaningful role in their desire to participate in our videoconference-based program. Although participants reported that session content was well suited to addressing stress management concerns, and session facilitators were able to effectively teach program techniques (eg progressive muscle relaxation, cognitive-reframing) and that the program was helpful overall, only modest improvements in perceived stress were seen. Participants noted challenges of the delivery including feeling disconnected from others, difficulty focusing, technical problems, and a desire for a longer program. Thus, although the novel delivery of a group-based, psychosocial program using tablet videoconference is feasible in a survivorship program, and desired by cancer survivors, key improvements must be made in future efforts. Our enthusiasm about the potential of telehealth must be tempered with the reality that such delivery can present challenges that interfere with the intervention implementation and efficacy. Facilitators must proactively address both the technological and interpersonal challenges associated with the use of group-based videoconference in order to improve its ability to positively impact cancer survivors. Many of these issues can be resolved prior to program launch, and require foresight and planning on the part of the program team.

Reference centres for adults with rare and complex cancers - Policy recommendations to improve the organisation of care in Belgium

BACKGROUND

Rare and/or complex cancers call for a very specific expertise and adequate infrastructure. In Belgium, every hospital with a programme in oncology can deliver care for adults with rare and/or complex cancer types, without having demonstrated a specific know-how to adequately manage these patients. Therefore, the Minister of Health ordered a scenario for the organisation of care for adults with rare and/or complex cancers, taking into account the current Belgian situation and relevant foreign experience.

METHODS

Combined methods were used in this study: a literature review, the consultation of stakeholders, in depth discussions in 14 multidisciplinary groups leading to concrete proposals for several rare/complex cancers and the consultation of a panel of expert pathologists.

RESULTS

The core recommendation is the set-up of shared care networks around reference centres, with multidisciplinary teams of recognised expertise in specific rare/complex cancers. The definition of minimum caseloads for hospitals and medical specialists, the evaluation of the quality of care, a model of diagnostic confirmation and the set-up of a national portal website which provides information on rare and/or complex cancers and reference centres are highly recommended.

CONCLUSION

It is no longer practicable, efficient or ethical that every hospital or every practitioner continues to offer care for every rare/complex cancer. Improving the quality of rare/complex cancer care requires to concentrate expertise and sophisticated infrastructure in reference centres. Furthermore, the formation of networks between reference centres and peripheral centres will allow a delivery of care combining expertise and proximity. The next step is the translation of the recommendations into policy decisions. It is very well realised that this will take some courage and that a certain degree of resistance will have to be surmounted, but eventually, the best interest of the patient should prevail.

Health System-Level Factors Influence the Implementation of Complex Innovations in Cancer Care

BACKGROUND

The movement of new knowledge and tools into healthcare settings continues to be a slow, complex and poorly understood process. In this paper, we present the system-level factors important to the implementation of synoptic reporting tools in two initiatives (or cases) in Nova Scotia, Canada.

METHODS

This study used case study methodology. Data were collected through interviews with key informants, document analysis, non-participant observation and tool use/examination. Analysis involved production of case histories, analysis of each case and a cross-case analysis.

RESULTS

The healthcare system's delivery and support structure, information technology infrastructure, policy environment and history of collaboration and inter-organizational relationships influenced tool implementation in the two cases.

CONCLUSIONS

The findings provide an in-depth, nuanced understanding of how healthcare system components can influence the implementation of a new tool in clinical practice.

Using clinical governance levers to support change in a cancer care reform

PURPOSE

Introducing change is a difficult issue facing all health care systems. The use of various clinical governance levers can facilitate change in health care systems. The purpose of this paper is to define clinical governance levers, and to illustrate their use in a large-scale transformation.

DESIGN/METHODOLOGY/APPROACH

The empirical analysis deals with the in-depth study of a specific case, which is the organizational model for Ontario's cancer sector. The authors used a qualitative research strategy and drew the data from three sources: semi-structured interviews, analysis of documents, and non-participative observations.

FINDINGS

From the results, the authors identified three phases and several steps in the reform of cancer services in this province. The authors conclude that a combination of clinical governance levers was used to transform the system. These levers operated at different levels of the system to meet the targeted objectives.

PRACTICAL IMPLICATIONS

To exercise clinical governance, managers need to acquire new competencies. Mobilizing clinical governance levers requires in-depth understanding of the role and scope of clinical governance levers.

ORIGINALITY/VALUE

This study provides a better understanding of clinical governance levers. Clinical governance levers are used to implement an organizational environment that is conducive to developing clinical practice, as well as to act directly on practices to improve quality of care.

Interventions targeting absences increase adherence and reduce abandonment of childhood cancer treatment in El Salvador

BACKGROUND

In El Salvador, about 200 new cases of pediatric cancer are diagnosed each year, and survival rates approach 70%. Although treatment is available at no cost, abandonment of therapy has remained at a steady yearly rate of 13% during the past decade. A time sensitive adherence tracking procedure (TS-ATP) was recently implemented to detect missed appointments, identify their causes, and intervene promptly. Procedure The study team was informed daily of patient/family failure to attend medical appointments in the pediatric oncology unit; the families were contacted and interviewed to ascertain and address the reasons. Patients who did not return after this initial contact were contacted again through local health clinics and municipalities. Law enforcement was a last resort for patients undergoing frontline treatment with a good prognosis., The system was adapted to clinical urgency: families of patients undergoing induction therapy were contacted within 24 hr, those in other therapy phases, within 48 hr, and those who had completed treatment, within one week. Reasons for absence were obtained by telephone or in person.

RESULTS

The annual rate of abandonment was reduced from 13-3% during the 2 years period. There were 1,111 absences reported and 1,472 contacts with caregivers and institutions. The three main reasons for absences were financial needs (165, 23%), unforeseen barriers (116, 16%), and domestic needs (86, 12%).

CONCLUSIONS

Use of the treatment adherence tracking system to locate and communicate with patients/families after missed appointments and the allocated aid stemming from these interviews substantially reduced abandonment and non-adherence.

Palliative care delivery models

OBJECTIVES

To provide an overview of the four major palliative care delivery models: ambulatory clinics, home-based programs, inpatient palliative care units, and inpatient consultation services. The advantages and disadvantages of each model and the generalist and specialist roles in palliative care will be discussed.

DATA SOURCES

Literature review.

CONCLUSION

The discipline of palliative care continues to experience growth in the number of programs and in types of delivery models. Ambulatory- and home-based models are the newest on the scene.

IMPLICATIONS FOR NURSING PRACTICE

Nurses caring for oncology patients with life-limiting disease should be informed about these models for optimal impact on patient care outcomes. Oncology nurses should demonstrate generalist skills in the care of the seriously ill and access specialist palliative care providers as warranted by the patient's condition.

[Status report of Hungarian radiotherapy based on treatment data, available infrastucture, and human resources]

The purpose of the study is to report the status of Hungarian radiotherapy (RT) based on the assessment of treatment data in years 2012 to 2014, available infrastructure, and RT staffing. Between December 2014 and January 2015, a RT questionnaire including 3 parts (1. treatment data; 2. infrastructure; 3. staffing) was sent out to all Hungarian RT centers (n=12). All RT centers responded to all questions of the survey. 1. Treatment data: In 2014, 33,162 patients were treated with RT: 31,678 (95.5%) with teletherapy, and 1484 (4.5%) with brachytherapy (BT). Between 2012 and 2014, the number of patients treated with radiotherapy increased with 6.6%, but the number of BT patients decreased by 11%. Forty-two percent of all patients were treated in the two centers of the capital: 9235 patients (28%) at the National Institute of Oncology (NIO), and 4812 (14%) at the Municipial Oncoradiology Center (MOC). Out of the patients treated on megavoltage RT units (n=22,239), only 901 (4%) were treated with intensity-modulated RT (IMRT), and 2018 (9%) with image-guided RT (IGRT). In 2014, 52% of all BT treatments were performed in Budapest: NIO - 539 patients (36%); MOC - 239 patients (16%); and BT was not available in 3 RT centers. Prostate I-125 seed implants and interstitial breast BT was utilized in one, prostate HDR BT in two, and head&neck implants in three centers. 2. Infrastructure: Including ongoing development projects funded by the European Union, by the end of year 2015, 39 megavoltage teletherapy units, and 12 HDR BT units will be in use in 13 available Hungarian RT centers. 3. Staffing: Actually, 92 radiation oncologists (RO), 29 RT residents, 61 medical physicists, and 229 radiation therapy technologists are working in 12 RT centers. There are 23 vacant positions (including 11 RO positions) available at the Hungarian RT centers. According to the professional minimal requirements and WHO guidelines, the implementation of 11 new linear accelerators, and 1 BT units are needed in Hungary. Further resources for the development and upgrade of RT infrastructure and capacity should be allocated to RT centers in Budapest. Brachytherapy and modern teletherapy (e.g. IMRT and IGRT) are underutilized in Hungary compared to other European countries. Implementation of continuous education and practical training programs in leading Hungarian and international RT centers are suggested in an effort to a wider implementation of modern RT techniques in Hungarian RT centers.