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.

[Opening of the Geneva University Hospital Prostate Cancer Center]

In 2014, Geneva University Hospital has opened the first certified prostate cancer Center of western Switzerland. It incorporates 29 entities implicated in the diagnosis and treatment of this disease, thereby assuring that all available ressources are made available to patients, regardless of the division to which they were initially referred. The main strength of the Center lies in the synergy generated by its multidisciplinary tumor board. Furthermore, regular conferences, staff meetings, propectively held registers and the yearly re-certification audit support its constant quality improvement.

Establishing of cancer units in low or middle income African countries: Angolan experience--a preliminary report

INTRODUCTION

The number of cancer cases and related deaths worldwide is expected to double over the next 20-30 years. African countries will be the most affected by the burden of cancer. The improving economic situation of Angola creates conditions for an increase in life expectancy which by itself is associated with an increased risk of oncological diseases. Because cancer therapy requires a multidisciplinary approach, trained health professionals, satisfactory infrastructure and appropriate facilities, the availability of effective cancer therapy is a difficult task that requires support. The aim of this article is to share our experience achieved in the establishment of cancer units in Angola and to validate our checklist for this action.

METHODS

The survey method was a questionnaire addressed to Angolan cancer units, in order to evaluate the usefulness and feasibility of a checklist developed by the authors--The Cancer Units Assessment Checklist for low or middle income African countries--which was used previously in the establishment of those units. Afterwards, the crucial steps taken for the establishing of the main sites of each cancer unit considering, facilities, resources and professionals, were also recorded.

RESULTS

All cancer units reported that the checklist was a useful tool in the development of the cancer program for the improvement of the unit or the establishing of cancer unit sites. This instrument helped identifying resources, defining the best practice and identifying barriers. Local experts, who know the best practices in oncology and who are recognized by the local heads, are also important and they proved to be the major facilitators.

CONCLUSION

The fight against cancer has just started in Angola. The training, education, advocacy and legislation are ongoing. According to our results, the assessment checklist for the establishment of cancer units is a useful instrument.

Cancer Core Europe: a consortium to address the cancer care-cancer research continuum challenge

European cancer research for a transformative initiative by creating a consortium of six leading excellent comprehensive cancer centres that will work together to address the cancer care-cancer research continuum. Prerequisites for joint translational and clinical research programs are very demanding. These require the creation of a virtual single 'e-hospital' and a powerful translational platform, inter-compatible clinical molecular profiling laboratories with a robust underlying computational biology pipeline, standardised functional and molecular imaging, commonly agreed Standard Operating Procedures (SOPs) for liquid and tissue biopsy procurement, storage and processing, for molecular diagnostics, 'omics', functional genetics, immune-monitoring and other assessments. Importantly also it requires a culture of data collection and data storage that provides complete longitudinal data sets to allow for: effective data sharing and common database building, and to achieve a level of completeness of data that is required for conducting outcome research, taking into account our current understanding of cancers as communities of evolving clones. Cutting edge basic research and technology development serve as an important driving force for innovative translational and clinical studies. Given the excellent track records of the six participants in these areas, Cancer Core Europe will be able to support the full spectrum of research required to address the cancer research- cancer care continuum. Cancer Core Europe also constitutes a unique environment to train the next generation of talents in innovative translational and clinical oncology.

Accountability in the ontario cancer services system: a qualitative study of system leaders' perspectives

Cancer Care Ontario (CCO), the provincial cancer agency, operates under a model of accountable governance that has been hailed as exemplary. We explored cancer system leaders' views on the balance and perceived efficacy of approaches to accountability in this context. Semi-structured interviews were conducted with 19 participants (MOHLTC=5, CCO=14). Adopting a qualitative descriptive approach, we coded data for four policy instruments used in approaches to accountability. Financial incentives are a key lever used by both parties to effect change. Cancer-specific regulations were somewhat weak, but agency-wide directives were a necessary nuisance that had great force. The effect of public reporting on mobilizing consumer sovereignty was questioned; however, transparency for its own sake was highly valued. Professionalism and stewardship, with an emphasis on trust-based partnerships and clinical engagement, were critical to CCO's success. These approaches were seen to work together, but what made each have force was reliance on professionalism and stewardship.

Challenges in organizing effective oncology service: inter-European variability in the example of head and neck cancers

The increasing worldwide burden of cancer makes it imperative that every country develop a comprehensive cancer control programme. In the past, cancer control in Central and Eastern Europe was inadequate, particularly when compared to many wealthier Western European countries. We analyse interregional differences in Europe to the approach to comprehensive cancer care, with a focus on head and neck squamous cell carcinoma using the case of Poland as a representative example. Due to national plans major improvements have been achieved in the field of prevention and in radiotherapy delivery having a measurable and positive impact on treatment outcomes. In head and neck cancers a notable move towards multidisciplinary approach has been made, combining surgery, radiotherapy and chemotherapy accompanied by rehabilitation and social support. In Poland and several other Eastern and Central European countries a shortage of physicians in the field of oncology was noted. The main conclusion is that the special plans are needed in Central and Eastern Europe or those existing must be extended for another decade to fulfil the EU requirement of providing all European citizens with equal access to quality cancer care.

In search of the economic sustainability of Hadron therapy: the real cost of setting up and operating a Hadron facility

PURPOSE

To determine the treatment cost and required reimbursement for a new hadron therapy facility, considering different technical solutions and financing methods.

METHODS AND MATERIALS

The 3 technical solutions analyzed are a carbon only (COC), proton only (POC), and combined (CC) center, each operating 2 treatment rooms and assumed to function at full capacity. A business model defines the required reimbursement and analyzes the financial implications of setting up a facility over time; activity-based costing (ABC) calculates the treatment costs per type of patient for a center in a steady state of operation. Both models compare a private, full-cost approach with public sponsoring, only taking into account operational costs.

RESULTS

Yearly operational costs range between €10.0M (M = million) for a publicly sponsored POC to €24.8M for a CC with private financing. Disregarding inflation, the average treatment cost calculated with ABC (COC: €29,450; POC: €46,342; CC: €46,443 for private financing; respectively €16,059, €28,296, and €23,956 for public sponsoring) is slightly lower than the required reimbursement based on the business model (between €51,200 in a privately funded POC and €18,400 in COC with public sponsoring). Reimbursement for privately financed centers is very sensitive to a delay in commissioning and to the interest rate. Higher throughput and hypofractionation have a positive impact on the treatment costs.

CONCLUSIONS

Both calculation methods are valid and complementary. The financially most attractive option of a publicly sponsored COC should be balanced to the clinical necessities and the sociopolitical context.

Physician behavior impact when revenue shifted from drugs to services

OBJECTIVES

In partnership with a large nonprofit healthcare insurer for the Mid-Atlantic region of the United States, we launched the first cancer clinical pathway in the United States in August 2008. Due to its early success with regard to savings and physician participation and compliance, a second-generation pathways program-the Oncology Medical Home-was piloted in 2011. This program offered a physician reimbursement model that shifted the source of revenue from drug reimbursement margin to professional charges for cognitive services (evaluation and management codes). We report our observations of the impact of that reimbursement model on physician prescribing behavior.

STUDY DESIGN

This was a retrospective analysis.

METHODS

A select group of practices that participated in the first-generation pathways program were invited to voluntarily participate in the Oncology Medical Home and its cognitive weighted reimbursement design. A matched control group was chosen from the first-generation pathways participants. Comparisons of physician behavior parameters were made pre- and postimplementation and between the Oncology Medical Home practices and the first-generation pathways control group.

RESULTS

Physician behavior was not significantly modified by cognitive weighted reimbursement. No significant change in frequency of office visits for established patients was observed. No change in chemotherapy prescribing was observed. Observed increases in generic regimen use were no different than matched control.

CONCLUSIONS

Observations from this oncology medical home pilot program suggest that reimbursement methodology alternatives to the prevailing fee-for-service may have less impact on prescribing behavior than has been conjectured. Future research is ongoing to validate these observations and assess additional influences on prescribing behavior.

Re-organisation of oesophago-gastric cancer services in England and Wales: a follow-up assessment of progress and remaining challenges

BACKGROUND

This study is an update on an earlier article in 2007 to assess the implementation of the Cancer Plan reform strategy in England and Wales.

FINDINGS

A national online survey to upper gastro-intestinal leads at network and trust level. The questionnaire was designed based on existing clinical practice guidelines and addressed governing principles and operational procedures related to the delivery of cancer care. It was sent in January 2012 to upper gastro-intestinal network and trusts leads at all cancer networks and acute NHS organisations in England and Wales. Responses were received from 100% of Cancer Networks and 91% of NHS organisations. Centralisation of surgery has improved with all but two trusts (5.4%) now meeting the minimum staffing level for oesophago-gastric cancer surgery. This is a substantial improvement since the 2007 survey when 21 trusts (46.7%) did not meet this requirement. The use of formal assessment for nutritional needs has improved, too. In 2007, the involvement of the palliative care team in multi-disciplinary teams was poor. While this has improved, 27 trusts (19.7%) still report that none of the palliative care team members routinely attend the multi-disciplinary team discussion.

CONCLUSIONS

The survey demonstrates improved compliance with organisational recommendations since the last assessment in 2007. Centralisation of surgery has improved and is nearly fully compliant with the reform strategy. Areas that require further improvement are nutritional support and inclusion of palliative care in multi-disciplinary team meetings.

Palliative care--integration model into oncological assistance for the patients of Regional Institute of Oncology Iasi

AIM

This paper aims to present a retrospective analysis of activity from Palliative Care Compartment of Regional Institute of Oncology Iasi during 12 months of activity and to propose a model of integration of the palliative care in oncology.

MATERIALS AND METHODS

Data were collected from 415 patients hospitalized to the Palliative Care Compartment using the computerized database, records and books of existing appointments.

RESULTS

Data analysis reveals that 170 cases (40%) were aged higher or equal to 70 years and a number of 142 patients (34%) were aged between 60-69 years. Results regarding the provenience of the patients shows that most of them are from urban areas. Gastrointestinal neoplasms were present at about one-third of the patients--133 cases (32%) and 95 (71%) of these cases had metastases. Most patients--114 cases (27%) required hospitalization for a period between 8 and 14 days. Palliative care has interdisciplinary relations with other specialties. In 2013 from other specialties were transferred to palliative care a number of 156 patients, most of them (87 cases) from Oncology Department.

CONCLUSIONS

Integrating palliative care in oncology would increase the quality of life of patients, would relieve the other sections or hospitals by patients who need palliative care, would decrease hospitalization costs and would avoid performing aggressive maneuvers at the end of life.

[Aristides Maltez Hospital and the control of cervical cancer in Brazil]

The Aristides Maltez Hospital in Salvador (Bahia) was inaugurated in 1952. The hospital was a philanthropic institution of the Bahian League Against Cancer. The Aristides Maltez Hospital specialised in cancer treatment, especially cervical cancer, and became a reference centre for the control of cancer in northeastern Brazil. This article follows the creation and consolidation of the hospital as a treatment, research, and training centre, evaluating its role in discussions and action networks on cervical cancer in the mid-20th century. The institution has been a space of transition in the use of diagnostic tools and the organisation of campaigns to control cancer in municipalities of the hinterland.

Oncologists' perspectives on concurrent palliative care in a National Cancer Institute-designated comprehensive cancer center

OBJECTIVE

The purpose of this study was to understand oncology clinicians' perspectives about the care of advanced cancer patients following the completion of the ENABLE II (Educate, Nurture, Advise, Before Life Ends) randomized clinical trial (RCT) of a concurrent oncology palliative care model.

METHOD

This was a qualitative interview study of 35 oncology clinicians about their approach to patients with advanced cancer and the effect of the ENABLE II RCT.

RESULTS

Oncologists believed that integrating palliative care at the time of an advanced cancer diagnosis enhanced patient care and complemented their practice. Self-assessment of their practice with advanced cancer patients comprised four themes: (1) treating the whole patient, (2) focusing on quality versus quantity of life, (3) “some patients just want to fight,” and (4) helping with transitions; timing is everything. Five themes comprised oncologists' views on the complementary role of palliative care: (1) “refer early and often,” (2) referral challenges: “Palliative” equals “hospice”; “Heme patients are different,” (3) palliative care as consultants or co-managers, (4) palliative care “shares the load,” and (5) ENABLE II facilitated palliative care integration.

SIGNIFICANCE OF RESULTS

Oncologists described the RCT as holistic and complementary, and as a significant factor in adopting concurrent care as a standard of care.

Outcomes assessment of a pharmacist-directed seamless care program in an ambulatory oncology clinic

The primary goal of seamless care is improved patient outcomes and improved standards of care for patients with cancer. The pharmacy service of the Newfoundland Cancer Treatment and Research Foundation conducted a randomized control study that measured clinical and humanistic outcomes of a pharmacist-directed seamless care program in an ambulatory oncology clinic. This article focuses on the intervention group, particularly the identification of drug-related problems (DRPs) and utilization of health care services as well the satisfaction of 3 types of health professionals with the services provided by the pharmacist-directed seamless care program. Overall, the seamless care pharmacist (SCP) identified an average of 3.7 DRPs per intervention patient; the most common DRP reported was a patient not receiving or taking a drug therapy for which there is an indication. The SCP identified more DRPs in patients receiving adjuvant treatment compared to those receiving palliative treatment. On average, family physicians, oncology nurses, and hospital pharmacists were satisfied with the SCP intervention indicating that they agreed the information collected and distributed by the SCP was useful to them. Pharmacist-directed seamless care services in an ambulatory oncology clinic have a significant impact on clinical outcomes and processes of patient care. The presence of a SCP can help identify and resolve DRPs experienced by patients in an outpatient oncology clinic, ensuring that patients are receiving the highest standard of care.