Virtual oncology clinics during the COVID-19 pandemic

Rapid Implementation of the Virtual Clinic Concept in an Oncology Department to Minimize the Exposure of Patients with Cancer to COVID-19

Introduction

The global pandemic was an emerging challenge that significantly impacted healthcare systems and the delivery of care. Prompt actions and adaptive techniques, such as the virtual clinic, were implemented to ensure the quality and continuity of the care provided. The aim of this quality improvement project was to ensure the smooth implementation and effectiveness of the virtual clinic during the COVID-19 crisis.

Methods

A specialized team of multidisciplinary healthcare providers was established to systematically ensure the implementation of the virtual clinic within the Department of Oncology. The team used multiple Plan-Do-Study-Act (PDSA) cycles of the quality improvement model to achieve the final goal and facilitate the transition to the virtual clinic.

Results

A total of 29 weekly virtual clinic sessions were conducted, covering various oncology services. From March to December 2020, 81% of the scheduled patients (3888) responded to virtual clinic calls. Physicians initiated 234 unplanned virtual clinic calls to follow up on a patient's condition. In addition, 916 medications were shipped to patients as needed. A patient satisfaction survey in May 2020 indicated an overall satisfaction rate of 92% with the virtual clinic process. Staff satisfaction was also high (91%), and 88% of the physicians believed that the virtual clinic would continue beyond the pandemic.

Conclusion

Implementing the virtual clinic is achievable through following systematic steps and effectively addressing emerging challenges as required. The concept of the virtual clinic was well accepted by patients and staff.

Digital solution in the follow-up of early breast cancer a randomized study

BACKGROUND

After primary treatment, patients with early breast cancer (EBC) are followed-up for at least 5 years. At the Helsinki University Hospital (HUS) surveillance includes appointments at 1, 3 and 5 years, and between pre-planned visits a phone call service operated by a nurse practitioner for counseling about symptoms related to side-effects or potential recurrence. In 2015 HUS launched a digital solution for cancer patients. This study was designed to find out patient preference, Health related (HR) quality of life (QOL) and satisfaction with a digital solution compared to a phone call service during the first year of follow-up.

MATERIAL AND METHODS

Patients with EBC were randomized at the final visit of radiotherapy to surveillance by phone calls or by the digital Noona solution during the first year outside pre-planned visits. After six months the groups were crossed over to the other arm. Primary endpoint was patient preference for either follow-up method among those who had contacted the study nurse at least once by both phone service and digital solution.

RESULTS

Out of the 765 patients randomized, 142 had contacted the hospital with both methods and were eligible for inclusion in the analyses of the present study. Out of the 142 patients, 56 preferred phone calls, 43 the digital solution while 43 considered both modalities equal. Preference for the digital solution was higher among patients aged 65 or less. There were no differences in HR QoL or overall satisfaction between the modalities. However, the patients rated the timeliness of response better while using the digital solution.

CONCLUSION

Of the patients 30% preferred the digital solution, 40% phone calls while 30% found them equal as the primary follow-up method for EBC during the first year outside pre-planned visits. There is a need to include also digital solutions in surveillance of EBC.

CLINICALTRIALS.GOV IDENTIFIER

NCT04980989.

Climate toxicity: An increasingly relevant clinical issue in Cancer Care

In recent years the terms time and financial toxicities have entered the vocabulary of cancer care. We would like to introduce another toxicity: climate toxicity. Climate toxicity is a double-edge sword in cancer care. Increasing cancer risk by exposure to carcinogens, and consequently increasing treatment requirements leads to ever growing damage to our environment. This article assesses the impact of climate change on patients, the climate toxicity caused by both healthcare workers and healthcare facilities, and suggests actions that may be taken mitigate them.

Impact of the COVID-19 pandemic on cancer care in Ireland - Perspectives from a COVID-19 and Cancer Working Group

Upon the COVID-19 pandemic onset in Ireland, cancer service disruptions occurred due to prioritisation of COVID-19 related care, redeployment of staff, initial pausing of screening, diagnostic, medical and surgical oncology procedures, staff shortages due to COVID-19 infection and impacts on the physical and mental health of cancer healthcare workers. This was coupled with reluctance among people with symptoms suspicious for cancer to attend for clinical evaluation, due to concerns of contracting the virus. This was further compounded by a cyber-attack on national health service IT systems on May 14th 2021. The Irish Cancer Society, a national cancer charity with a role in advocacy, research and patient supports, convened a multi-disciplinary stakeholder group (COVID-19 and Cancer Working Group) to reflect on and understand the impact of the pandemic on cancer patients and services in Ireland, and discuss potential mitigation strategies. Perspectives on experiences were gathered across domains including timeliness of data acquisition and its conversion into intelligence, and the resourcing of cancer care to address cancer service impacts. The group highlighted aspects for future research to understand the long-term pandemic impact on cancer outcomes, while also highlighting potential strategies to support cancer services, build resilience and address delayed diagnosis. Additional measures include the need for cancer workforce recruitment and retention, increased mental health supports for both patients and oncology professionals, improvements to public health messaging, a near real-time multimodal national cancer database, and robust digital and physical infrastructure to mitigate impacts of the current pandemic and future challenges to cancer care systems.

Software-Tool Support for Collaborative, Virtual, Multi-Site Molecular Tumor Boards

The availability of high-throughput molecular diagnostics builds the foundation for Molecular Tumor Boards (MTBs). Although more fine-grained data is expected to support decision making of oncologists, assessment of data is complex and time-consuming slowing down the implementation of MTBs, e.g., due to retrieval of the latest medical publications, assessment of clinical evidence, or linkage to the latest clinical guidelines. We share our findings from analysis of existing tumor board processes and defininion of clinical processes for the adoption of MTBs. Building on our findings, we have developed a real-world software prototype together with oncologists and medical professionals, which supports the preparation and conduct of MTBs and enables collaboration between medical experts by sharing medical knowledge even across the hospital locations. We worked in interdisciplinary teams of clinicians, oncologists, medical experts, medical informaticians, and software engineers using design thinking methodology. With their input, we identified challenges and limitations of the current MTB approaches, derived clinical process models using Business Process and Modeling Notation (BMPN), and defined personas, functional and non-functional requirements for software tool support. Based on it, we developed software prototypes and evaluated them with clinical experts from major university hospitals across Germany. We extended the Kanban methodology enabling holistic tracking of patient cases from "backlog" to "follow-up" in our app. The feedback from interviewed medical professionals showed that our clinical process models and software prototype provide suitable process support for the preparation and conduction of molecular tumor boards. The combination of oncology knowledge across hospitals and the documentation of treatment decision can be used to form a unique medical knowledge base by oncologists for oncologists. Due to the high heterogeneity of tumor diseases and the spread of the latest medical knowledge, a cooperative decision-making process including insights from similar patient cases was considered as a very valuable feature. The ability to transform prepared case data into a screen presentation was recognized as an essential feature speeding up the preparation process. Oncologists require special software tool support to incorporate and assess molecular data for the decision-making process. In particular, the need for linkage to the latest medical knowledge, clinical evidence, and collaborative tools to discuss individual cases were named to be of importance. With the experiences from the COVID-19 pandemic, the acceptance of online tools and collaborative working is expected to grow. Our virtual multi-site approach proved to allow a collaborative decision-making process for the first time, which we consider to have a positive impact on the overall treatment quality.

A permanent legacy of the pandemic? Outcomes of and staff views on the introduction of virtual clinics to an Irish oncology service

BACKGROUND

Virtual clinics were introduced to our practice in March 2020. We aimed to assess outcomes from virtual clinics and to assess staff views on them and their barriers to implementation nationally.

METHODS

We prospectively assessed outcomes from 53 planned virtual consultations in a cancer centre oncology outpatient department (April-July 2020). Thirty-two oncologists completed an online survey.

RESULTS

Visit durations ranged from < 5 min (n = 2, 4%) to 30 + min/patient (n = 9, 20%) (median: 18 min (range 4-141, IQR 10-30 min)). Median time spent preparing for patients who did not attend (n = 6, 11%) was 15 min (range 9-15 min). Most patients were scheduled for routine follow-up (n = 41, 87%), with some planned for an early in-person visit (n = 3) or investigation (n = 3). Where bloods had been requested (n = 25), samples had often not been taken (n = 20, 80%) or results were unavailable (n = 3, 12%). Different plans may have been agreed with two patients (4%) had they attended in-person. Virtual visits were perceived as faster by most doctors in the online survey (n = 26, 84%), with some (n = 5, 16%) reporting a difference of 10 min per patient. Many (n = 13, 42%) arranged earlier follow-up appointments. Low satisfaction was associated with difficulty with patient assessment (81%) or communication (63%), resource limitation (48%), or poor access to results of investigations (40%). The majority (n = 21, 67%) do not feel their virtual clinic quality is as good as in-person.

CONCLUSIONS

If virtual clinics are to play a long-term role in oncology, it is essential to monitor clinic quality and plan visits proactively.

'It made me feel part of the team, having my homework to do' - women and specialist nurse experiences of remote follow-up after ovarian cancer treatment: a qualitative interview study

PURPOSE

Ovarian cancer patients require monitoring for relapse post-treatment, and alternative follow-up pathways are increasing, which require in-depth exploration to ensure acceptability and inform implementation. This study aimed to explore women and specialist nurses' experiences of participating in a feasibility study of an electronic patient-reported outcome (ePRO) follow-up pathway after ovarian cancer treatment.

METHODS

The feasibility study incorporated an ePRO questionnaire, blood test and telephone consultation with a specialist nurse, instead of face-to-face hospital visits. All women and the nurses involved were invited to take part in nested semi-structured interviews. Interviews were recorded and transcripts analysed using framework analysis.

RESULTS

Twenty interviews were conducted (16 out of 24 women who took part in the feasibility study and all 4 nurses). Four themes were identified: (1) readiness and motivators, (2) practicalities and logistics, (3) personal impact and (4) future role. An overarching theme highlighted how women strived to seek reassurance and gain confidence. Most women and nurses were positive about the ePRO pathway and would happily continue using it.

CONCLUSION

This work provides invaluable insight into the experiences of women on remote ePRO follow-up post-treatment. Important logistic and implementation issues were identified, which should inform future large-scale work to introduce and evaluate remote ePRO methods in cancer follow-up. This work highlights the key factors influencing women's readiness and acceptability of an ePRO pathway, and how services should be carefully designed to ensure patients feel reassured and confident post-treatment. Furthermore, it highlights that flexibility and patient preference should be considered in remote service delivery.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT02847715 (first registered 19 May 2016).

Mitigating the Impact of the COVID-19 Pandemic on Adult Cancer Patients through Telehealth Adoption: A Systematic Review

During the first wave of the COVID-19 pandemic, the delivery of life-saving and life-prolonging health services for oncology care and supporting services was delayed and, in some cases, completely halted, as national health services globally shifted their attention and resources towards the pandemic response. Prior to March 2020, telehealth was starting to change access to health services. However, the onset of the global pandemic may mark a tipping point for telehealth adoption in healthcare delivery. We conducted a systematic review of literature published between January 2020 and March 2021 examining the impact of the COVID-19 pandemic on adult cancer patients. The review's inclusion criteria focused on the economic, social, health, and psychological implications of COVID-19 on cancer patients and the availability of telehealth services emerged as a key theme. The studies reviewed revealed that the introduction of new telehealth services or the expansion of existing telehealth occurred to support and enable the continuity of oncology and related services during this extraordinary period. Our analysis points to several strengths and weaknesses associated with telehealth adoption and use amongst this cohort. Evidence indicates that while telehealth is not a panacea, it can offer a "bolstering" solution during a time of disruption to patients' access to essential cancer diagnostic, treatment, and aftercare services. The innovative use of telehealth has created opportunities to reimagine the delivery of healthcare services beyond COVID-19.

Experiencia del paciente oncológico durante la pandemia por el COVID-19 y su opinión sobre la telemedicina

Objetivo: la pandemia por el COVID-19 está generando un importante impacto emocional en la población general y, en especial, en los pacientes crónicos, como los oncológicos. Además, ha supuesto cambios en la atención sanitaria. El presente estudio pretende conocer este impacto, en la población oncológica y, desde su propia experiencia, explorar sus estrategias de afrontamiento así como conocer su opinión sobre la atención sanitaria recibida. Metodología: participaron 118 pacientes pertenecientes a 5 centros hospitalarios de la provincia de Barcelona. Los datos fueron recogidos a través del cuestionario HADS y de un cuestionario ad-hoc para valorar el malestar emocional, las estrategias de afrontamiento, la percepción de riesgo de contagio, el apoyo social y los cambios ocurridos en la atención sanitaria. Resultados: el 51,4% de los participantes puntuaron alto en la escala de ansiedad y un 36% en la de depresión. La preocupación (73,7%), el miedo (72,8%), la ansiedad (56,1%) y la tristeza (56,1%) fueron las emociones más frecuentemente expresadas. El 74,1% se sintieron muy satisfechos con la atención sanitaria recibida y el 94,6% refirieron haberse sentido acompañados por su equipo sanitario. Respecto a la valoración de la telemedicina, un 40,7% manifestaron no estar a favor de esta alternativa mientras que el 33,7% consideraron que era una buena opción. Conclusiones: los pacientes oncológicos consideran que la pandemia ha afectado negativamente a su estado emocional y su calidad de vida. Conocer la opinión que tienen los pacientes sobre la telemedicina nos puede ayudar a definir más adecuadamente el uso de este tipo de asistencia.