Cancer Care Coordination: a Systematic Review and Meta-Analysis of Over 30 Years of Empirical Studies

Respect for the Patient-Oncologist Relationship May Limit Serious Illness Communication by Acute and Postacute Care Clinicians After Discharge to a Skilled Nursing Facility

PURPOSE

There is a need to increase palliative care access for hospitalized older adults with cancer discharged to a skilled nursing facility (SNF) at risk of poor outcomes. Assessing and Listening to Individual Goals and Needs (ALIGN) is a palliative care intervention developed to address this gap. This study gathered perspectives from clinicians across care settings to describe perceptions on serious illness communication and care coordination for patients with cancer after discharge to a SNF to guide ALIGN refinements.

METHODS

We conducted 37 semistructured interviews with clinicians and leaders in hospital medicine (n = 12), oncology (n = 9), palliative care (n = 12), home health care (n = 6), and hospice (n = 4). Some participants had experience working in more than one specialty. The Practical Robust Implementation and Sustainability Model framework was used to develop the interview guide that explored barriers to care, prognosis discussions, and hospice recommendations. Interviews were coded and analyzed using thematic content analysis.

RESULTS

Analysis identified four themes: (1) discharge to a SNF is recognized as a time of worsening prognosis; (2) care silos create communication and information barriers during a period of increasing palliative care need; (3) family caregiver distress escalates following care transitions; and (4) lack of clarity of roles and respect for the patient-oncologist relationship limits prognostic communication and changes in focus of treatment.

CONCLUSION

These findings suggest that acute and postacute care clinicians defer serious illness conversations to the oncologist when patients are on a steep trajectory of decline, experiencing multiple care transitions, and may have limited contact with their oncologist. There is a need to clarify roles among nononcology and oncology clinicians in discussing prognosis and recommending hospice for older adults discharged to SNF.

Identifying the unmet needs of post-treatment colorectal cancer survivors: A critical literature review

PURPOSE

Following treatment completion, colorectal cancer (CRC) survivors experience various unmet needs. This review aims to synthesize the unmet needs of CRC survivors after treatment and to identify demographic, disease or treatment-related, healthcare-related, and psychosocial factors correlated with unmet needs.

METHOD

English or Chinese articles that focused on CRC survivors' post-treatment unmet needs were systematically searched from the five electronic databases, which included CINAHL, PubMed, Embase, PsycINFO, and the China Academic Journal Full-text Database, from the launch of databases to July 2023. The reference lists of the subsequent articles were further screened.

RESULTS

136 individual needs extracted from 50 manuscripts were classified into nine domains based on the Supportive Care Framework. The top four unmet needs identified by CRC survivors were assistance with fears of cancer recurrence, information about managing illness and side effects at home, emotional or psychological support and reassurance, and help with sexuality problems. Following surgery, CRC survivors showed strong demand in the physical, psychological, and information domains. Survivors completed treatment within 1-year had more diverse needs than those who completed 1-3 years. Unmet needs may be greater among CRC survivors who were young, female, more educated, and unmarried. Furthermore, greater unmet needs were associated with distress, anxiety, depression, and worse quality of life.

CONCLUSIONS

Despite diverse needs experienced by post-treatment CRC survivors, a predominant focus on fears of cancer recurrence, information, psychological support, and sexuality needs is noted. Future studies should further explore the needs of CRC survivors after specific treatment and in different post-treatment periods.

Patient Perceptions of Care Coordination during Neoadjuvant Therapy for Gastrointestinal Cancers: A Mixed Methods Analysis

PURPOSE

Effective cancer care coordination (CCC) is an integral component of health care delivery and critical to achieving optimal oncologic outcomes. Neoadjuvant therapy (NT), the delivery of multimodality therapy prior to surgery, is inherently complex and multidisciplinary, but CCC during NT is poorly understood. The objective of this study was to characterize patient perceptions of CCC during NT using a mixed methods approach.

METHODS

This study is a cross-sectional analysis of patients with gastrointestinal cancers receiving NT who participated in a prospective longitudinal cohort study evaluating their real-time experience using a customized smartphone application. Patients completed the Cancer Care Coordination Questionnaire for Patients (CCCQ-P), a 20-item validated measure of care coordination quality, six weeks after initiating NT. Items were scored on a 5-point Likert scale, and subsections on communication (13 questions) and navigation (7 questions) were calculated with higher scores signifying better CCC. Univariate linear regression was used to calculate the impact of fragmented care and other factors on perceived CCC. Semi-structured interviews were conducted among a convenience sample of patients (n = 5); transcribed interviews were then coded using an inductive approach.

RESULTS

Among 82 participants, mean age was 61 years old, 68% were male, and mean number of comorbidities was 1.68. Overall (mean 76.6 out of 100), communication subsection (48.6 out of 65), and navigation subsection (28.0 out of 35) CCCQ-P scores suggested overall positive perceptions of care coordination. Qualitative analysis of patient interviews highlighted the need for coordination among physicians before communicating the plan to patients as well as the importance of providers communicating plans in verbal and written form.

CONCLUSIONS

Successful completion of NT requires significant care coordination between patients and healthcare professionals. Yet, in this cross-sectional analysis of patients on a prospective cohort study, patient perceptions of CCC during NT were overall positive. Future research should focus on optimizing other aspects of care delivery in order to improve outcomes of NT.

Transitional Care Navigation

OBJECTIVES

This manuscript aims to provide an extensive review of the literature, synthesize findings, and present substantial insights on the current state of transitional care navigation. Additionally, the existing models of care, pertaining to the concept and approach to transitional care navigation, will be highlighted.

METHODS

An extensive search was conducted though using multiple search engines, topic-specific key terminology, eligibility of studies, as well as a limitation to only literature of existing relevance. Integrity of the evidence was established through a literature review matrix source document. A synthesis of nursing literature from organizations and professional publications was used to generate a comparison among various sources of evidence for this manuscript. Primary evidence sources consisted of peer-reviewed journals and publications from professional organizations such as the AHRQ, Academic Search Premier, CINAHL Plus with Full Text, and the Talbot research library.

RESULTS

A total of five systematic reviews (four with meta-analysis) published between 2016 and 2022 and conducted in several countries (Brazil, Korea, Singapore, and the US) were included in this review. A combined total of 105 studies were included in the systematic reviews with 53 studies included in meta-analyses. The review of the systematic reviews identified three overarching themes: care coordination, care transition, and patient navigation. Care coordination was associated with an increase in care quality rating, increased the health-related quality of life in newly diagnosed patients, reduced hospitalization rates, reduced emergency department visits, timeliness in care, and increased appropriateness of healthcare utilization. Transitional care interventions resulted to reduced average number of admissions in the intervention (I) group vs control (C) (I = 0.75, C = 1.02) 180 days after a 60-day intervention, reduced readmissions at 6 months, and reduced average number of visits 180 days after 60-day intervention (I = 2.79, C = 3.60). Nurse navigators significantly improved the timeliness of care from cancer screening to first-course treatment visit (MD = 20.42, CI = 8.74 to 32.10, P = .001).

CONCLUSION

The care of the cancer patient entails treatments, therapies, and follow-up care outside of the hospital setting. These transitions can be challenging as they require coordination and collaboration among various health care sites. The attributes of transitional care navigation overlap with care coordination, care transition, and patient navigation. There is an opportunity to formally develop a transitional care navigation model to effectively addresses the challenges in care transitions for patient including barriers to health professional exchange of information or communication across care settings and the complexity of coordination between care settings. The transitional care navigation and clinic model developed at a free-standing NCI-designated comprehensive cancer center is a multidisciplinary approach created to close the gaps in care from hospital to home.

IMPLICATIONS FOR NURSING PRACTICE

A transitional care navigation model aims to transform the existing perspectives and viewpoints of hospital discharge and transition of care to home or post-acute care settings as two solitary processes to that of a collective approach to care. The model supports provides an integrated continuum of quality, comprehensive care that supports patient compliance with treatment regimens, reinforces patient and caregiver education, and improves health outcomes.

Relationship between patient outcomes and patterns of fragmented cancer care in older adults with gastric cancer: A nationwide cohort study in South Korea

INTRODUCTION

Fragmented cancer care, defined as receipt of care from multiple hospitals, has been shown to be associated with poor patient outcomes and high expense. However, evidence regarding the effects of hospital choice by patients with cancer on overall survival are lacking. Thus, we investigated the relationship between patterns of fragmented care and five-year mortality in patients with gastric cancer.

MATERIALS AND METHODS

Using the Korean National Health Insurance senior cohort of adults aged ≥60 years, we identified patients with gastric cancer who underwent gastrectomy during 2007-2014. We examined the distribution of the study population by five-year mortality, and used Kaplan-Meier survival curves/log-rank test and Cox proportional hazard model to compare five-year mortality with fragmented cancer care.

RESULTS

Among the participants, 19.5% died within five years. There were more deaths among patients who received fragmented care, especially those who transferred to smaller hospitals (46.6%) than to larger ones (40.0%). The likelihood of five-year mortality was higher in patients who received fragmented cancer care upon moving from large to small hospitals than those who did not transfer hospitals (hazard ratio, 1.28; 95% confidence interval, 1.10-1.48, P = .001). Moreover, mortality was higher among patients treated in large hospitals or in the capital area for initial treatment, and this association was greater for patients from rural areas.

DISCUSSION

Fragmentation of cancer care was associated with reduced survival, and the risk of mortality was higher among patients who moved from large to small hospitals.

Patient reports of cancer care coordination in rural Hawaii

PURPOSE

Rural residents experience disproportionate burdens of cancer, and poorer cancer health outcomes in rural populations are partly attributed to care delivery challenges. Cancer patients in rural areas often experience unique challenges with care coordination. In this study, we explored patient reports of care coordination among rural Hawaii patients with cancer and compared rural and urban patients' perceptions of cancer care coordination.

METHODS

80 patients receiving active treatment for cancer from rural Hawaii participated in a care coordination study in 2020-2021. Participants completed the Care Coordination Instrument, a validated oncology patient questionnaire.

FINDINGS

Mean age of rural cancer patients was 63.0 (SD = 12.1), and 57.7% were female. The most common cancer types were breast and GI. Overall, rural and urban patients' perceptions of care coordination were comparable (p > 0.05). There were statistically significant differences between rural and urban patients' perceptions in communication and navigation aspects of care coordination (p = 0.02 and 0.04, respectively). Specific differences included a second opinion consultation, clinical trial considerations, and after-hours care. 43% of rural patients reported traveling by air for part or all of their cancer treatment.

CONCLUSIONS

Findings suggest that while overall perceptions of care coordination were similar between rural and urban patients, differential perceptions of specific care coordination areas between rural and urban patients may reflect limited access to care for rural patients. Improving access to cancer care may be a potential strategy to enhance care coordination for rural patients and ultimately address rural-urban cancer health disparities.

Availability of cancer survivorship support services across the National Cancer Institute Community Oncology Research Program network

BACKGROUND

National cancer organizations recommend provision of nutrition, physical activity, and mental health supportive services to cancer survivors. However, the availability of these services across diverse community oncology settings remains unclear.

METHODS

The National Cancer Institute Community Oncology Research Program (NCORP) is a national network of community oncology practices engaged in cancer research. The 2022 NCORP Landscape Assessment (5UG1CA189824) assessed individual practices' establishment of survivorship clinics and nutrition, physical activity, and mental health services, resources, and/or referrals. Descriptive statistics summarized and logistic regression quantified the association between services, practice, and patient characteristics.

RESULTS

Of 46 NCORP community sites, 45 (98%) responded to the survey, representing 259 adult practice groups. A total of 41% had a survivorship clinic; 96% offered mental health, 94% nutrition, and 53% physical activity services, resources, and/or referrals. All 3 services were offered in various formats (eg, in-house, referrals, education) by 51% and in-house only by 25% of practices. Practices with advanced practice providers were more likely to have a survivorship clinic (odds ratio [OR] = 3.19, 95% confidence interval [CI] = 1.04 to 9.76). Practices with at least 30% Medicare patients (OR = 2.54, 95% CI = 1.39 to 4.66) and more oncology providers (OR = 1.02, 95% CI = 1.01 to 1.04) were more likely to have all 3 services in any format. Practices with at least 30% Medicare patients (OR = 3.41, 95% CI = 1.50 to 7.77) and a survivorship clinic (OR = 2.84, 95% CI = 1.57 to 5.14) were more likely to have all 3 services in-house.

CONCLUSIONS

Larger oncology practices and those caring for more survivors on Medicare provided more supportive services, resources, and/or referrals. Smaller practices and those without survivorship clinics may need strategies to address potential gaps in supportive services.

The interplay of financial toxicity, health care team communication, and psychosocial well-being among rural cancer patients and survivors

BACKGROUND

Financial toxicity contributes to psychosocial distress among cancer patients and survivors. Yet, contextual factors unique to rural settings affect patient experiences, and a deeper understanding is needed of the interplay between financial toxicity and health care team communication and its association with psychosocial well-being among rural oncology patients.

PURPOSE

We examined associations between financial toxicity and psychosocial well-being among rural cancer patients, exploring variability in these linkages by health care team communication.

METHODS

Using data from 273 rural cancer patients who participated in Cancer Support Community's Cancer Experience Registry, we estimated multivariable regression models predicting depression, anxiety, and social function by financial toxicity, health care team communication, and the interplay between them.

RESULTS

We demonstrate robust associations between financial toxicity and psychosocial outcomes among our sample of rural cancer patients and survivors. As financial toxicity increased, symptoms of depression and anxiety increased. Further, financial toxicity was linked with decreasing social function. Having health care team conversations about treatment costs and distress-related care reduced the negative impact of financial toxicity on depressive symptoms and social function, respectively, in rural cancer patients at greatest risk for financial burden.

CONCLUSIONS

Financial toxicity and psychosocial well-being are strongly linked, and these associations were confirmed in a rural sample. A theorized buffer to the detrimental impacts of financial toxicity-health care team communication-played a role in moderating these associations. Our findings suggest that health care providers in rural oncology settings may benefit from tools and resources to bolster communication with patients about costs, financial distress, and coordination of care.

The Best Supportive Care in Stage III Non-Small-Cell Lung Cancer

Lung cancer is a major cause of cancer deaths worldwide. Non-small-cell lung cancer (NSCLC) represents most lung cancer cases, and approximately one-third of patients present with stage III disease at diagnosis. As multiple treatment plans can be adopted for these patients depending on tumor size and nodal staging, stage III NSCLC management is challenging. Over the past decades, multidisciplinary teams (MDTs) have been implemented in healthcare services to coordinate actions among the different health care professionals involved in cancer care. The aim of this review was to discuss real-world evidence of the impact of MDTs on stage III NSCLC management, survival, and quality of life. Here, we performed a literature review to investigate the role of nutrition and navigational nursing in NSCLC care and the influence of MDTs in the choice of treatment plans, including immunotherapy consolidation, and in the management of chemotherapy and radiotherapy-related adverse events. We also performed a mapping review to identify gaps in the implementation of cancer care MDTs in healthcare services around the world.

Factors influencing implementation of a care coordination intervention for cancer survivors with multiple comorbidities in a safety-net system: an application of the Implementation Research Logic Model

BACKGROUND

Under- and uninsured cancer survivors have significant medical, social, and economic complexity. For these survivors, effective care coordination between oncology and primary care teams is critical for high-quality, comprehensive care. While evidence-based interventions exist to improve coordination between healthcare teams, testing implementation of these interventions for cancer survivors seen in real-world safety-net settings has been limited. This study aimed to (1) identify factors influencing implementation of a multicomponent care coordination intervention (nurse coordinator plus patient registry) focused on cancer survivors with multiple comorbidities in an integrated safety-net system and (2) identify mechanisms through which the factors impacted implementation outcomes.

METHODS

We conducted semi-structured interviews (patients, providers, and system leaders), structured observations of primary care and oncology operations, and document analysis during intervention implementation between 2016 and 2020. The practice change model (PCM) guided data collection to identify barriers and facilitators of implementation; the PCM, Consolidated Framework for Implementation Research, and Implementation Research Logic Model guided four immersion/crystallization data analysis and synthesis cycles to identify mechanisms and assess outcomes. Implementation outcomes included appropriateness, acceptability, adoption, and penetration.

RESULTS

The intervention was appropriate and acceptable to primary care and oncology teams based on reported patient needs and resources and the strength of the evidence supporting intervention components. Active and sustained partnership with system leaders facilitated these outcomes. There was limited adoption and penetration early in implementation because the study was narrowly focused on just breast and colorectal cancer patients. This created barriers to real-world practice where patients with all cancer types receive care. Over time, flexibility intentionally designed into intervention implementation facilitated adoption and penetration. Regular feedback from system partners and rapid cycles of implementation and evaluation led to real-time adaptations increasing adoption and penetration.

DISCUSSION

Evidence-based interventions to coordinate care for underserved cancer survivors across oncology and primary care teams can be implemented successfully when system leaders are actively engaged and with flexibility in implementation embedded intentionally to continuously facilitate adoption and penetration across the health system.

Barriers, facilitators, and priority needs related to cancer prevention, control, and research in rural, persistent poverty areas

PURPOSE

The purpose of this study was to identify the barriers, facilitators, and priority needs related to cancer prevention, control, and research in persistent poverty areas.

METHODS

We conducted three focus groups with 17 providers and staff of primary care clinics serving persistent poverty areas throughout the state of Arkansas.

RESULTS

We identified multiple barriers, facilitators, and priority needs related to cancer prevention and control at primary care clinics serving persistent poverty areas. Barriers included transportation, medical costs, limited providers and service availability, and patient fear/discomfort with cancer topics. Facilitators identified were cancer navigators and community health events/services, and priority needs included patient education, comprehensive workflows, improved communication, and integration of cancer navigators into healthcare teams. Barriers to cancer-related research were lack of provider/staff time, patient uncertainty/skepticism, patient health literacy, and provider skepticism/concerns regarding patient burden. Research facilitators included better informing providers/staff about research studies and leveraging navigators as a bridge between clinic and patients.

CONCLUSION

Our results inform opportunities to adapt and implement evidence-based interventions to improve cancer prevention, control, and research in persistent poverty areas. To improve cancer prevention and control, we recommend locally-informed strategies to mitigate patient barriers, improved patient education efforts, standardized patient navigation workflows, improved integration of cancer navigators into care teams, and leveraging community health events. Dedicated staff time for research, coordination of research and clinical activities, and educating providers/staff about research studies could improve cancer-related research activities in persistent poverty areas.

Facilitating family communication of familial hypercholesterolemia genetic risk: Assessing engagement with innovative chatbot technology from the IMPACT-FH study

Objective

To assess use of two web-based conversational agents, the Family Sharing Chatbot (FSC) and One Month Chatbot (OMC), by individuals with familial hypercholesterolemia (FH).

Methods

FSC and OMC were sent using an opt-out methodology to a cohort of individuals receiving a FH genetic result. Data from 7/1/2021 through 5/12/2022 was obtained from the electronic health record and the chatbots' HIPAA-secure web portal.

Results

Of 175 subjects, 21 (12%) opted out of the chatbots. Older individuals were more likely to opt out. Most (91/154, 59%) preferred receiving chatbots via the patient EHR portal. Seventy-five individuals (49%) clicked the FSC link, 62 (40%) interacted, and 36 (23%) shared a chatbot about their FH result with at least one relative. Ninety-two of the subjects received OMC, 22 (23%) clicked the link and 20 (21%) interacted. Individuals who shared were majority female and younger on average than the overall cohort. Reminders tended to increase engagement.

Conclusion

Results demonstrate characteristics relevant to chatbot engagement. Individuals may be more inclined to receive chatbots if integrated within the patient EHR portal. Frequent reminders can potentially improve chatbot utilization.

Innovation

FSC and OMC employ innovative digital health technology that can facilitate family communication about hereditary conditions.

Hearing the Voices of Australian Thyroid Cancer Survivors: Qualitative Thematic Analysis of Semistructured Interviews Identifies Unmet Support Needs

Background: Most thyroid cancer survivors regain their physical health-related quality of life, but psychological and social deficits persist. The nature of these detriments remains poorly understood and they are insufficiently captured by survey data alone. To address this, qualitative data exploring the breadth and depth of thyroid cancer survivors' experiences and priorities for supportive care are required. Methods: Twenty semistructured interviews were undertaken with a purposive, maximum variation sample of thyroid cancer survivors. Interviews were transcribed verbatim and coded independently by two researchers. A hybrid model of inductive and realistic codebook analysis was undertaken with themes developed. Results: Patient experiences centered around three themes: (1) impact of diagnosis and treatment, (2) thyroid cancer does not happen in isolation, and (3) role of clinicians and formalized support structures. The word "cancer" had negative connotations, but for many, the reality of their experience was more positive. Despite feeling "lucky" at the relative low-risk nature of thyroid cancer, many patients reported fatigue, weight gain, and difficulty returning to usual activities; concerns that were largely dismissed or minimized by clinicians. Few were offered any support beyond their treating doctors; where patients attempted to access formalized supportive care, little was available or appropriate. Life stage and concurrent family and social stressors greatly impacted patients' ability to cope with diagnosis and treatment. Addressing thyroid cancer in isolation felt inappropriate without appreciating the broader context of their lives. Interactions with clinicians were largely positive, particularly where information was communicated as a means of empowering patients to participate in shared decision-making and where clinicians "checked in" emotionally with patients. Information about initial treatments was largely adequate but information on longer term effects and follow-up was lacking. Many patients felt that clinicians focused on physical well-being and scan results, missing opportunities to provide psychological support. Conclusions: Thyroid cancer survivors can struggle to navigate their cancer journey, particularly with regard to psychological and social functioning. There is a need to acknowledge these impacts at the time of clinical encounters, as well as develop information resources and support structures that can be individualized to optimize holistic well-being for those in need.

[Utilizing Patient Navigation Model in the Whole-Process Management of Lung Cancer in the Context of Medical Consortiums in China: Insights and Reflections]

Patient navigation is an effective intervention measure to promote the integration of medical systems and services. By providing individualized, coordinated, and continuous care, patient navigation offers a way to address the problem of fragmented services across institutions and levels of care in the whole-process management of lung cancer, providing assistance to patients with complex healthcare needs. Herein, we reviewed the origin, the development, the models, and the application status of patient navigation in China and other countries. We also analyzed the considerations regarding introducing patient navigation in the whole-process management of lung cancer against the background of medical consortiums in China, discussing why patient navigation should be introduced, how to introduce patient navigation, as well as potential challenges and coping strategies. Patient navigation meets the current needs for equitable, accessible, systematic, continuous, and integrated prevention and treatment services for chronic diseases in the context of the Healthy China Strategy. It helps fill the gaps in the continuity and coordination of whole-process management of lung cancer patients in the context of medical consortiums. However, introducing patient navigation in medical consortiums involving multiple institutions and levels of care may face challenges, including incompatibility between the health information systems of different institutions, poor cross-institutional collaboration and communication, and limited resources. Further improvement is needed in medical informatization, coordination and communication mechanisms, and benefit distribution mechanisms within the medical consortiums. In this paper, we intend to provide insights and suggestions for developing patient navigation models that suit China's local characteristics and for promoting the implementation and development of whole-process management of lung cancer in the context of the medical consortium system.

Trade-offs in locational choices for care coordination resources in accountable care organizations

BACKGROUND

Care coordination is central to accountable care organizations (ACOs), especially in Medicaid where many patients have complex medical and social needs. Little is known about how to best organize care coordination resources in this context, particularly whether to centralize them. We examined how care coordinators' location, management, and colocation of both (within ACO headquarters, practice sites, or other organizations) relate to care quality and coordination.

METHODS

We conducted a cross-sectional analysis of surveys administered to a sample of practice sites covering all 17 Medicaid ACOs in Massachusetts ( n = 225, response rate = 64%). We applied controlled, cluster-robust regressions, adjusting the significance threshold for the number of ACO clusters, to assess how clinical information sharing across settings, care quality improvement, knowledge of social service referral, and cross-resource coordination (i.e., the ability of multiple resources to work well together) relate to where care coordinators were physically located and/or managed.

RESULTS

Centralizing care coordinators at ACO headquarters was associated with greater information sharing. Embedding care coordinators in practices was associated with greater care quality improvement. Embedding coordinators at other organizations was associated with less information sharing and care quality improvement. Managing coordinators at practice sites and other organizations were associated with better care quality improvement and cross-resource coordination, respectively. Colocating the two functions showed no significant differences.

PRACTICE IMPLICATIONS

Choosing care coordinators' locations may present trade-offs. ACOs may strategically choose embedding care coordinators at practice sites for enhanced care quality versus centralizing them at the ACO to facilitate information sharing.

Associations between healthcare costs and care experiences among older adults with and without cancer

INTRODUCTION

Care coordination and patient-provider communication are important for older adults with cancer, as they likely have additional, non-cancer chronic conditions requiring consultation across multiple providers. Suboptimal care coordination and patient-provider communication can lead to costly and preventable adverse outcomes. This study examines Medicare expenditures associated with patient-reported care coordination and patient-provider communication among older adults with and without cancer.

MATERIALS AND METHODS

We explore SEER-CAHPS® (Surveillance, Epidemiology and End Results-Consumer Assessment of Healthcare Providers and Systems) linked data for differences in health care expenditures by care coordination and patient-provider communication experiences for beneficiaries with and without cancer. The cancer cohort included beneficiaries with ten prevalent cancer types diagnosed 2011-2019 at least six months before completing a CAHPS survey. Medicare expenditures were abstracted from Medicare claims data. Care coordination and patient-provider communication composite scores (range 0-100, higher scores indicate better experiences) were patient-reported in the CAHPS® survey. We estimated expenditure differences per one-point change in composite scores for patients with and without cancer.

RESULTS

Our analysis included 16,778 matched beneficiaries with and without a previously diagnosed cancer (N = 33,556). Higher care coordination and patient-provider communication scores were inversely associated with Medicare expenditures among beneficiaries with and without cancer in the six months prior to survey response, ranging from -$83 (standard error [SE] = $7) to -$90 (SE = $6) per month. Six months post-survey, expenditures estimates ranging -$88 (SE = $6) to -$106 (SE = $8) were found.

DISCUSSION

We found that lower Medicare expenditures were associated with higher care coordination and patient-provider communication scores. As the number of survivors living longer both with and beyond their cancer grows, addressing their multifaceted care and improving outcomes will be critical.

Care coordination in homecare and its relationship with quality of care: A national multicenter cross-sectional study

INTRODUCTION

As health care complexity increases, skilled care coordination is becoming increasingly necessary. This is especially true in homecare settings, where services tend to be highly interprofessional. Poor coordination can result in services being provided twice, at the wrong time, unnecessarily or not at all. In addition to risking harm to the client, such confusion leads to unnecessary costs. From the patient's perspective, then, professional coordination should help both to remove barriers limiting quality of care and to minimize costs. To date, though, studies examining the relationship between care coordination and care quality have faced multiple challenges, leading to mixed results. And in homecare contexts, where the clients are highly vulnerable and diverse care interfaces make coordination especially challenging, such studies are rare.

OBJECTIVES

Therefore, the aim of this study was to explore the relationship, from the perspectives of clients and of homecare professionals, between coordination and quality of care. For both groups, we hypothesized that better coordination would correlate with higher ratings of quality of care. For the clients, we predicted that higher coordination ratings would lead to lower incidence of unplanned health care use, i.e., emergency department (ED) visits, unscheduled urgent medical visits and hospitalizations.

DESIGN AND METHODS

This study is part of a national multi-center cross-sectional study in the Swiss homecare setting. We recruited 88 homecare agencies and collected data between January and September 2021 through written questionnaires for agencies' managers, employees (n = 3223) and clients (n = 1509). To test our hypotheses, we conducted multilevel analyses.

RESULTS

Employee-perceived care coordination ratings correlated positively with employee-rated quality of care (OR = 2.78, p < .001); client-perceived care coordination problems correlated inversely with client-reported quality of care (β = -0.55, p < .001). Client-perceived coordination problems also correlated positively with hospitalizations (IRR = 1.20, p < .05) and unscheduled urgent medical visits (IRR = 1.18, p < .05), but not significantly with ED visits. No associations were discernible between employee-perceived coordination quality and either health care service use or client quality-of-care ratings.

DISCUSSION

While results indicate relationships between coordination and diverse aspects of care quality, various coordination gaps (e.g., poor information flow) also became apparent. The measurement of both care coordination and quality of care remains a challenge. Further research should focus on developing and validating a coordination questionnaire that measures care coordination.

A descriptive study of policy and system-level interventions to address cancer survivorship issues across six United States health systems

PURPOSE

To describe policy and system-level interventions with potential to improve cancer care at six sites.

METHODS

In 2016, six institutions received foundation support to develop unique multi-component interventions aimed at improving cancer care for underserved populations. These organizations, located across the United States, participated in a cross-site evaluation to assess the overall initiative impact and to identify potentially promising policy and system-level solutions for dissemination and broader implementation. A health system and policy tracking tool was developed to collect data from each site and included a description of their efforts, strategies employed, and changes achieved (e.g., new policies, clinical protocols). Tracking tool data were analyzed using rapid qualitative analyses and a matrix approach. Semi-structured interviews were conducted with site leaders (N = 65) and were analyzed by thematic analysis.

RESULTS

Sites reported 20 system and policy efforts, which resulted in improvements to electronic health records and telehealth strategies, changes to hospital/health system policies, and standardized clinical protocols/guidelines, among others. Efforts were aimed at: (1) coordinating care across multiple providers, supported by patient navigators; (2) expanding psychosocial and supportive care; (3) improving patient-provider communication; and (4) addressing barriers to accessing care. Interview analyses provided insights into successful strategies, challenges, and implications of the COVID-19 pandemic on cancer care.

CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS

Despite advances in diagnosis and treatment, cancer care remains inequitable. System-level improvements aimed at eliminating common barriers faced by underserved populations offer opportunities to improve the delivery of equitable, effective, and efficient care.

"Somebody was standing in my corner": a mixed methods exploration of survivor, coach, and hospital staff perspectives and outcomes in an Australian cancer survivorship program

PURPOSE

Cancer survivorship in Australia continues to increase due to new methods for early detection and treatment. Cancer survivors face challenges in the survivorship phase and require ongoing support. A telephone-delivered cancer survivorship program (CSP), including health and mental health coaches, was developed, piloted, and evaluated in Eastern Australia.

METHODS

Cancer survivors' (n = 7), coaches' (n = 7), and hospital staff (n = 3) experiences of the CSP were explored through semi-structured interviews. Quantitative data routinely collected throughout the pilot of the CSP was described (N = 25).

RESULTS

Three syntheses and 11 themes were generated through thematic analysis. The first synthesis centred around operational factors and highlighted a need to streamline communication from the point of recruitment, through to program delivery, emphasising that the program could be beneficial when timed right and tailored correctly. The second synthesis indicated that the CSP focused on appropriate information, filled a gap in support, and met the needs of cancer survivors by empowering them. The third synthesis focussed on the value of mental health support in the CSP, but also highlighted challenges coaches faced in providing this support. Descriptive analysis of quantitative data indicated improvements in self-management, weekly physical activity, and meeting previously unmet needs.

CONCLUSIONS

Cancer survivors expressed appreciation for the support they received through the CSP and, in line with other cancer survivorship research, predominantly valued just having somebody in their corner.

IMPLICATIONS FOR CANCER SURVIVORS

Recommendations are made for improving cancer survivorship programs in the future.

Treatment burden in individuals living with and beyond cancer: A systematic review of qualitative literature

BACKGROUND

Individuals with cancer are being given increasing responsibility for the self-management of their health and illness. In other chronic diseases, individuals who experience treatment burden are at risk of poorer health outcomes. Less is known about treatment burden and its impact on individuals with cancer. This systematic review investigated perceptions of treatment burden in individuals living with and beyond cancer.

METHODS AND FINDINGS

Medline, CINAHL and EMBASE databases were searched for qualitative studies that explored treatment burden in individuals with a diagnosis of breast, prostate, colorectal, or lung cancer at any stage of their diagnostic/treatment trajectory. Descriptive and thematic analyses were conducted. Study quality was assessed using a modified CASP checklist. The review protocol was registered on PROSPERO (CRD42021145601). Forty-eight studies were included. Health management after cancer involved cognitive, practical, and relational work for patients. Individuals were motivated to perform health management work to improve life-expectancy, manage symptoms, and regain a sense of normality. Performing health care work could be empowering and gave individuals a sense of control. Treatment burden occurred when there was a mismatch between the resources needed for health management and their availability. Individuals with chronic and severe symptoms, financial challenges, language barriers, and limited social support are particularly at risk of treatment burden. For those with advanced cancer, consumption of time and energy by health care work is a significant burden.

CONCLUSION

Treatment burden could be an important mediator of inequities in cancer outcomes. Many of the factors leading to treatment burden in individuals with cancer are potentially modifiable. Clinicians should consider carefully what they are asking or expecting patients to do, and the resources required, including how much patient time will be consumed.

Care coordination across healthcare systems: development of a research agenda, implications for practice, and recommendations for policy based on a modified Delphi panel

OBJECTIVE

For large, integrated healthcare delivery systems, coordinating patient care across delivery systems with providers external to the system presents challenges. We explored the domains and requirements for care coordination by professionals across healthcare systems and developed an agenda for research, practice and policy.

DESIGN

The modified Delphi approach convened a 2-day stakeholder panel with moderated virtual discussions, preceded and followed by online surveys.

SETTING

The work addresses care coordination across healthcare systems. We introduced common care scenarios and differentiated recommendations for a large (main) healthcare organisation and external healthcare professionals that contribute additional care.

PARTICIPANTS

The panel composition included health service providers, decision makers, patients and care community, and researchers. Discussions were informed by a rapid review of tested approaches to fostering collaboration, facilitating care coordination and improving communication across healthcare systems.

OUTCOME MEASURES

The study planned to formulate a research agenda, implications for practice and recommendations for policy.

RESULTS

For research recommendations, we found consensus for developing measures of shared care, exploring healthcare professionals' needs in different care scenarios and evaluating patient experiences. Agreed practice recommendations included educating external professionals about issues specific to the patients in the main healthcare system, educating professionals within the main healthcare system about the roles and responsibilities of all involved parties, and helping patients better understand the pros and cons of within-system and out-of-system care. Policy recommendations included supporting time for professionals with high overlap in patients to engage regularly and sustaining support for care coordination for high-need patients.

CONCLUSIONS

Recommendations from the stakeholder panel created an agenda to foster further research, practice and policy innovations in cross-system care coordination.

Fragmentation of Care and Its Association With Survival and Costs for Patients With Breast Cancer in Colombia

PURPOSE

Breast cancer care requires a multimodal approach and a multidisciplinary team who must work together to obtain good clinical results. The fragmentation of care can affect the breast cancer care; however, it has not been measured in a low-resource setting. The aim of this study was to identify fragmentation of care, the geographic variation of this and its association with 4-year overall survival (OS), and costs of care for patients with breast cancer enrolled in Colombia's contributory health care system.

MATERIALS AND METHODS

A retrospective cohort study was conducted using administrative databases. Women with breast cancer who were treated from January 1, 2013, to December 31, 2015, were included. Fragmentation of care was the exposure, which was measured by the number of different health care provider institutions (HCPIs) that treated a patient during the first year after diagnosis. Crude mortality rates were estimated, survival functions were calculated using the nonparametric Kaplan-Meier approach, and adjusted hazard ratios (HRs) were estimated using multivariate Cox regression model to identify the association of fragmentation with 4-year OS. The association between fragmentation and costs of care was assessed using a multivariate linear regression model.

RESULTS

A total of 10,999 patients with breast cancer were identified, and 1,332 deaths were observed. The 4-year crude mortality rate was 31.97 (95% CI, 30.25 to 33.69) per 1,000 person-years for the whole cohort, and the highest rate was in the cohort defined for the fourth quartile of the fragmentation measurement (eight or more HCPIs), 40.94 (95% CI, 36.49 to 45.39). The adjusted HR for 4-year OS was 1.04 (95% CI, 1.01 to 1.07) for each HCPI additional. The cost of care is increased for each additional HCPIs (cost ratio, 1.25; 95% CI, 1.23 to 1.26).

CONCLUSION

Fragmentation of care decreases overall 4-year OS and increases the costs of care in women with breast cancer for Colombia.

Are Nurse Coordinators Really Performing Coordination Pathway Activities? A Comparative Analysis of Case Studies in Oncology

Patient Pathway Coordination (PPC) improves patient care quality and safety, particularly in oncology. PPC roles, such as nurse coordinators (NCs), have positively impacted the quality of patient care and reduced financial costs. However, NCs and their real activities in Health Care Organizations (HCOs) are unclear. Our aim was to identify, quantify, and compare all activities performed by NCs in oncology care settings from an organizational approach. Methods: We used qualitative and quantitative approaches based on case study principles. We accumulated 325 observation hours by shadowing and timing the activities of 14 NCs in four French HCO in oncology. Data analysis was conducted using an analytical framework to investigate the Activity of PAtient PAthway Nurse Coordinators in Oncology (APANCO). Results: Our research generated important findings: (1) NC roles and job titles are not standardized. (2) Non-coordination related activities are important in NC work content. Non-coordination times were consistent with distribution times between ward NCs and NCs in centralized structures. Ward NCs had higher non-coordination activities when compared with NCs in centralized structures. (3) PPC times varied for both ward NCs and NCs in centralized structures. Ward NCs performed less design coordination when compared with NCs in centralized structures, and this latter group also performed more external coordination than ward NCs. Conclusions: NCs do not just perform PPC activities. Their position in HCO structures, wards, or centralized structures, influence their work content. Centralized structures allow NCs to focus on their PPC roles. We also highlight different dimensions of NC work and training requirements. Our study could help managers and decision-makers develop PPC roles in oncology.

Understanding the activity of oncology nurse coordinators: An elaboration of a framework based on an abductive approach

Care coordination is a major health system issue, in particular for cancer patients where a lack of coordination may impact quality of care, lived experiences, and care costs. Consequently, new roles facilitating Patient Pathway Coordination (PPC) have been created (nurse coordinators, NC). However, despite their importance, core PPC activities remain unclear. Practices are often heterogeneous and may be far removed from coordination roles, thus posing issues for implementation of PPC policies. To address this, we generated an analytical framework to investigate the Activity of PAtient PAthway Nurse Coordinators in Oncology (APANCO) from an organizational perspective. We adopted an abductive approach, characterized by two phases: the first involved a preliminary theoretical framework confronted with empirical data from two ethnographic fieldwork scenarios. In the second, we confronted the updated framework with data from a care coordination literature review. The final APANCO framework comprised three main categories at micro-level and three at meso-level. The first categories were used to analyze real NC activity at the micro-level and accounted for activities related (or not) to PPC. Meso-level categories considered organizational contexts that might have influenced NC work content. APANCO provided invaluable information on NCs activities. The framework may be used for clinical and managerial skills training and for standardizing job descriptions. These elements are key for decision-makers and managers who implement PPC programs.

Preferences of older adults for healthcare models designed to improve care coordination: evidence from Western Switzerland

Implementing innovations in care delivery in Switzerland is challenging due to the fragmented nature of the system and the specificities of the political process (i.e., direct democracy, decentralized decision-making). In this context, it is particularly important to account for population preferences when designing policies. We designed a discrete choice experiment to study population preferences for coordination-improving care models. Specifically, we assessed the relative importance of model characteristics (i.e., insurance premium, presence of care coordinator, access to specialists, use of EMR, cost-sharing for chronic patients, incentives for informal care), and predicted uptake under different policy scenarios. We accounted for heterogeneity in preferences for the status quo option using an error component logit model. Respondents attached the highest importance to the price attribute (i.e. insurance premium) (0.31, CI: 0.27- 0.36) and to the presence of a care coordinator (0.27, CI: 0.23 - 0.31). Policy scenarios showed for instance that gatekeeping would be preferred to free access to specialists if the model includes a GP or an interprofessional team as a care coordinator. Although attachment to the status quo is high in the studied population, there are potential ways to improve acceptance of alternative care models by implementation of positively valued innovations.

Impact of breast cancer care pathways and related symptoms on the return-to-work process: results from a population-based French cohort study (CONSTANCES)

BACKGROUND

Breast cancer (BC) treatments and related symptoms may affect return to work (RTW). The objective of this study was to investigate the impact of BC care pathways (timing and sequence of treatments) and related symptoms on RTW.

METHODS

The study population included working-age women with BC who were enrolled in the French CONSTANCES cohort from 2012 to 2018. BC treatments, antidepressant/anxiolytic and antalgic drug deliveries (used as proxies of depression and pain, respectively) and statutory sick pay (used to estimate RTW and time to RTW) were assessed monthly using data from the French national healthcare system database. BC care pathways were identified with the sequence analysis method. Cox models with time-dependent covariates were used to investigate the impact of BC care pathways and related symptoms on RTW and time to RTW, after adjusting for age and socioeconomic characteristics.

RESULTS

73.2% (231/303) of women returned to work within 2 years after BC diagnosis. Five BC care pathway patterns were identified: (i) BC surgery only, (ii) BC surgery and radiotherapy, (iii) BC surgery and chemotherapy, (iv) BC surgery and chemotherapy and radiotherapy, and (v) BC surgery and long-term alternative chemotherapy/radiotherapy. The hazards ratios of non-RTW were significantly higher for women who received BC surgery and long-term alternative chemotherapy/radiotherapy and for > 55-year-old women. Time to RTW was significantly longer in women who received chemotherapy (patterns iii to v) and in women with antidepressant/anxiolytic and antalgic drug deliveries.

CONCLUSION

This study highlights the value of considering the dynamic, cumulative and temporal features of BC care pathways and related symptoms to facilitate the RTW of women with BC.

Vertical integration of oncologists and cancer outcomes and costs in metastatic castration-resistant prostate cancer

BACKGROUND

The share of oncology practices owned by hospitals (ie, vertically integrated) nearly doubled from 2007 to 2017. We examined how integration between hospitals and oncologists affected care quality, outcomes, and spending among metastatic castration-resistant prostate cancer (mCRPC) patients.

METHODS

Using Surveillance, Epidemiology, and End Results-Medicare linked data and the Medicare Data on Provider Practice and Specialty, we identified Medicare beneficiaries who initiated systemic therapy for mCRPC between 2008 and 2017 (n = 9172). Primary outcomes included 1) bone-modifying agents (BMA) use, 2) time on systemic therapy, 3) survival, and 4) Medicare spending for the first 3 months following therapy initiation. We used a differences-in-differences approach to estimate the impact of vertical integration on outcomes, adjusting for patient and provider characteristics.

RESULTS

The proportion of patients treated by integrated oncologists increased from 28% to 55% from 2008 to 2017. Vertical integration was associated with an 11.7 percentage point (95% confidence interval [CI] = 4.2 to 19.1) increased likelihood of BMA use. There were no satistically significant changes in time on systemic therapy, survival, or total per-patient Medicare spending. Further decomposition showed an increase in outpatient payment ($5190, 95% CI = $1451 to $8930) and decrease in professional service payment (-$4757, 95% CI = -$7644 to -$1870) but no statistically significant changes for other service types (eg, inpatient and prescription drugs).

CONCLUSIONS

Vertical integration was associated with statistically significant increased BMA use but not with other cancer outcomes among mCRPC patients. For oncologists who switched service billing from physician offices to outpatient departments, there was no statistically significant change in overall Medicare spending in the first 3 months of therapy initiation. Future studies should extend the investigation to other cancer types and patient outcomes.

Web-Based Asynchronous Tool to Facilitate Communication Between Primary Care Providers and Cancer Specialists: Pragmatic Randomized Controlled Trial

BACKGROUND

Cancer poses a significant global health burden. With advances in screening and treatment, there are now a growing number of cancer survivors with complex needs, requiring the involvement of multiple health care providers. Previous studies have identified problems related to communication and care coordination between primary care providers (PCPs) and cancer specialists.

OBJECTIVE

This study aimed to examine whether a web- and text-based asynchronous system (eOncoNote) could facilitate communication between PCPs and cancer specialists (oncologists and oncology nurses) to improve patient-reported continuity of care among patients receiving treatment or posttreatment survivorship care.

METHODS

In this pragmatic randomized controlled trial, a total of 173 patients were randomly assigned to either the intervention group (eOncoNote plus usual methods of communication between PCPs and cancer specialists) or a control group (usual communication only), including 104 (60.1%) patients in the survivorship phase (breast and colorectal cancer) and 69 (39.9%) patients in the treatment phase (breast and prostate cancer). The primary outcome was patient-reported team and cross-boundary continuity (Nijmegen Continuity Questionnaire). Secondary outcome measures included the Generalized Anxiety Disorder Screener (GAD-7), Patient Health Questionnaire on Major Depression, and Picker Patient Experience Questionnaire. Patients completed the questionnaires at baseline and at 2 points following randomization. Patients in the treatment phase completed follow-up questionnaires at 1 month and at either 4 months (patients with prostate cancer) or 6 months following randomization (patients with breast cancer). Patients in the survivorship phase completed follow-up questionnaires at 6 months and at 12 months following randomization.

RESULTS

The results did not show an intervention effect on the primary outcome of team and cross-boundary continuity of care or on the secondary outcomes of depression and patient experience with their health care. However, there was an intervention effect on anxiety. In the treatment phase, there was a statistically significant difference in the change score from baseline to the 1-month follow-up for GAD-7 (mean difference -2.3; P=.03). In the survivorship phase, there was a statistically significant difference in the change score for GAD-7 between baseline and the 6-month follow-up (mean difference -1.7; P=.03) and between baseline and the 12-month follow-up (mean difference -2.4; P=.004).

CONCLUSIONS

PCPs' and cancer specialists' access to eOncoNote is not significantly associated with patient-reported continuity of care. However, PCPs' and cancer specialists' access to the eOncoNote intervention may be a factor in reducing patient anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03333785; https://clinicaltrials.gov/ct2/show/NCT03333785.

Associations among navigational support and health care utilization and costs in patients with advanced cancer: An analysis based on administrative health insurance data

BACKGROUND

Fragmented and complex healthcare systems make it difficult to provide continuity of care for patients with advanced cancer near the end of life. Nurse-based cross-sectoral navigation support has the potential to increase patients' quality of life. The objective of this paper was to evaluate associations between navigation support and health care utilization, and the associated costs of care.

METHODS

The evaluation is based on claims data from 37 statutory health insurance funds. Non-randomized recruitment of the intervention group (IG) took place between 2018 and 2019 in four German hospitals. The comparison group (CG) was defined ex post. It comprises nonparticipating clients of the involved health insurance funds matched on age, gender, and diagnosis in a 1:4 ratio to the IG. Healthcare resource utilization was compared using incident rate ratios (IRRs) based on negative binomial regression models. Linear mixed models were performed to compare differences in lengths of hospital stays and costs between groups.

RESULTS

A total of 717 patients were included (IG: 149, CG: 568). IG patients showed shorter average lengths of hospital stays (IG: 11 days [95% CI: 10, 13] vs. CG: 15 days [95% CI: 14, 16], p < 0.001). In the IG, 21% fewer medications were prescribed and there were on average 15% fewer outpatient doctor contacts per month. Average billed costs in the IG were 23% lower than in the CG (IG: 6754 EUR [95% CI: 5702, 8000] vs. CG: 8816 EUR [95% CI: 8153, 9533], p < 0.001).

CONCLUSIONS

The intervention was associated with decreased costs mainly as a result of a non-intended navigation effect. The social care nurses had navigated patients within the hospital early, needs-oriented and effectively but interpreted their function less cross-sectorally. Linkage of hospital-based navigators with the outpatient care sector needs further exploration.

Fostering a High-Functioning Team in Cancer Care Using the 4R Oncology Model: Assessment in a Large Health System and a Blueprint for Other Institutions

PURPOSE

Delivering cancer care by high-functioning multidisciplinary teams promises to address care fragmentation, which threatens care quality, affects patient outcomes, and strains the oncology workforce. We assessed whether the 4R Oncology model for team-based interdependent care delivery and patient self-management affected team functioning in a large community-based health system.

METHODS

4R was deployed at four locations in breast and lung cancers and assessed along four characteristics of high-functioning teams: recognition as a team internally and externally; commitment to an explicit shared goal; enablement of interdependent work to achieve the goal; and engagement in regular reflection to adapt objectives and processes.

RESULTS

We formed an internally and externally recognized team of 24 specialties committed to a shared goal of delivering multidisciplinary care at the optimal time and sequence from a patient-centric viewpoint. The team conducted 40 optimizations of interdependent care (22 for breast, seven for lung, and 11 for both cancers) at four points in the care continuum and established an ongoing teamwork adaptation process. Half of the optimizations entailed low effort, while 30% required high level of effort; 78% resulted in improved process efficiency.

CONCLUSION

4R facilitated development of a large high-functioning team and enabled 40 optimizations of interdependent care along the cancer care continuum in a feasible way. 4R may be an effective approach for fostering high-functioning teams, which could contribute to improving viability of the oncology workforce. Our intervention and taxonomy of results serve as a blueprint for other institutions motivated to strengthen teamwork to improve patient-centered care.

IMPACT the Brain: A Team-Based Approach to Management of Metastatic Breast Cancer With CNS Metastases

PURPOSE

CNS metastases are associated with decreased survival and quality of life for patients with metastatic breast cancer (MBC). Team-based care can optimize outcomes. IMPACT the Brain is a care coordination program that aims to improve access to team-based care for patients with MBC and CNS metastases.

MATERIALS AND METHODS

Patients with MBC and CNS metastases were eligible for enrollment in this care coordination program. A team of specialists supported a dedicated program coordinator who provided navigation, education, specialty referral, and clinical trial screening. A unique intake form developed for the program created personalized, coordinated, and expedited specialty referrals. Patient-reported outcomes and caregiver burden assessments were collected on a voluntary basis throughout enrollment. Data were analyzed using descriptive statistics.

RESULTS

Sixty patients were referred, and 53 were enrolled (88%). The median time to program enrollment was 1 day (range, 0-11) and to first visit was 5 days (range, 0-25). On the basis of the program intake form, 47 referrals were made across six specialties, most commonly physical medicine and rehabilitation (n = 10), radiation oncology (n = 10), and neuropsychology (n = 10). Nineteen patients (36%) consented to enroll in clinical trials.

CONCLUSION

A tailored team-based care coordination program for patients with MBC and CNS metastases is feasible. Use of a unique intake screening form by a dedicated program coordinator resulted in faster time to first patient visit, enabled access to subspecialist care, and supported enrollment in clinical trials. Future research should focus on intervention development using PRO data collected in this care coordination program.

Making Every Meeting Count: A Qualitative Investigation of Multiteam Meeting Events and Their Role in Supporting Coordinated Cancer Care Delivery

PURPOSE

This research considers how cross-disciplinary cancer care meetings can facilitate coordination within the multiteam systems (MTSs) that provide inpatient hospital care. We conducted a series of interviews and observations with members of a single cancer care MTS to address the following research questions: (1) what are the key characteristics of MTS cancer care meetings (with regard to composition, focus, and structure)? and (2) how is cross-team coordination acknowledged and addressed during these meetings?

METHODS

In this single-site case study of a MTS operating to provide gynecologic oncology care within a teaching hospital, two types of meetings, called rounds and huddles, were held consistently. We used qualitative methods, including interviews with health care professional subject matter experts and 30 hours of observations of cancer care meetings, and analyzed the data in three stages of qualitative coding.

RESULTS

Our analyses resulted in a thematic framework detailing key processes, and subprocesses, identified as central to the activities of observed cancer care meetings. Key processes include information sharing, gaining clarity, strategizing, and pedagogy. Discussions and explanations of this framework showcase the ways in which MTS meetings can bolster cross-team coordination and facilitate MTS activities.

CONCLUSION

Inpatient cancer care meetings provide opportunities to facilitate MTS coordination in several ways, yet doing so does not come without challenges. Considering these results together with insights from meeting science and MTS research, this article concludes by putting forward practical recommendations for leveraging opportunities and overcoming challenges to use cancer care meetings as tools to support cross-team coordination.

Incomplete patient information exchange and unnecessary repeat diagnostics during oncological referrals in the Netherlands: exploring the role of information exchange

Data management in transmural care is complex. Without digital innovations like Health Information Exchange (HIE), patient information is often dispersed and inaccessible across health information systems between hospitals. The extent of information loss and consequences remain unclear. We aimed to quantify patient information availability of referred oncological patients and to assess its impact on unnecessary repeat diagnostics by observing all oncological multidisciplinary team meetings (MDTs) in a tertiary hospital. During 84 multidisciplinary team meetings, 165 patients were included. Complete patient information was provided in 17.6% (29/165, CI = 12.3-24.4) of patients. Diagnostic imaging was shared completely in 52.5% (74/141, CI = 43.9-60.9), imaging reports in 77.5% (100/129, CI = 69.2-84.2), laboratory results in 55.2% (91/165, CI = 47.2-62.8), ancillary test reports in 58.0% (29/50, CI = 43.3-71.5), and pathology reports in 60.0% (57/95, CI = 49.4-69.8). A total of 266 tests were performed additionally, with the main motivation not previously performed followed by inconclusive or insufficient quality of previous tests. Diagnostics were repeated unnecessarily in 15.8% (26/165, CI = 10.7-22.4) of patients. In conclusion, patient information was provided incompletely in majority of referrals discussed in oncological multidisciplinary team meetings and led to unnecessary repeat diagnostics in a small number of patients. Additional research is needed to determine the benefit of Health Information Exchange to improve data transfer in oncological care.

Caring Transitions - A Care Coordination Intervention to Reduce Suicide Risk Among Youth Discharged From Inpatient Psychiatric Hospitalization

Background: Suicide risk following youth psychiatric hospitalization is of significant concern. This study evaluated Linking Individuals Needing Care (LINC), a theory-driven, comprehensive care coordination approach for youth discharged from crisis services. Aims: To pilot LINC's potential effectiveness in increasing service utilization and decreasing suicide risk. Method: Participants were 460 youth patients who received LINC for approximately 90 days following discharge from crisis services. Service utilization, depressive symptoms, and suicide-related variables were measured at baseline and 30, 60, and 90 days after baseline. Results: Patients significantly increased the use of various beneficial, least restrictive services (individual therapy, medication management, and non-mental health supports) over the 90-day intervention. Significant decreases were observed in depressive symptoms, suicide ideation, and engagement in suicide-related behaviors. Limitations: Absence of a comparison group and nonparticipating families limit causal conclusions and generalizability. Conclusions: LINC may be a promising new approach following inpatient hospitalization that can engage and retain youth in services, likely resulting in improved treatment outcomes. This approach was designed emphasizing patient engagement, suicide risk assessment and management, safety planning, community networking, referral/linkage monitoring, coping and motivational strategies, and linguistic/culturally responsive practices to meet service and support needs of high-risk suicidal youth.

The Emerging Boon of Information and Communication Technology in Multidisciplinary Cancer Care: A Force Multiplier With a Human Touch

Cancer care (CC) is incredibly complex and requires the coordination of multiple disciplines for optimal outcomes. Historically, this has been accomplished with multidisciplinary tumor boards (MDTBs), but the benefits, while perhaps intuitive, have not always been demonstrated with sufficient research robustness and validity. We hypothesize that this difficulty in demonstrating the benefit of MDTBs may be related to a delay in decision-making and operationalizing those decisions. The history and value of MDTBs are presented as well as their weaknesses and limited demonstration of improved outcomes. A major weakness highlighted by the challenges of MDTBs is the concept of total package time (TPT) (rather, the inability to keep it as short as possible); any significant delays in CC for any discipline may have a deleterious impact on any given patient's care outcome. Drawing on our own experience with utilizing information and communication technology (ICT) during an effort to apply accountability theory to improve specifically radiation therapy package time (RTPT), we argue that similar principles will be applicable in the improvement of not only the TPT which relies on multiple disciplines, but other factors of CC as well, such as coordination. Experience with improvement in RTPT is discussed and the underlying theory is demonstrated as a sound methodology to apply beyond RTPT to TPT involving coordination of multiple disciplines and stands to lead to the full realization of the benefits of the multidisciplinary approach. The complexity of cancer means that real solutions to optimal outcomes are also, by nature, complex, but here simple accountability theory is demonstrated that may unlock the next phase of multidisciplinary coordination. In this work, we argue that the benefits of the MDTB format can be fully realized with the addition of ICT, a technological breakthrough in the past two decades, while not forgetting about continued human factors.

Barriers and facilitators to early-stage lung cancer care in the USA: a qualitative study

PURPOSE

Improved outcomes in lung cancer treatment are seen in high-volume academic centers, making it important to understand barriers to accessing care at such institutions. Few qualitative studies examine the barriers and facilitators to early-stage lung cancer care at US academic institutions.

METHODS

Adult patients with suspected or diagnosed early-stage non-small cell lung cancer presenting to a multidisciplinary lung cancer clinic at a US academic institution over a 6-month period beginning in 2019 were purposively sampled for semi-structured interviews. Semi-structured interviews were conducted and a qualitative content analysis was performed using the framework method. Themes relating to barriers and facilitators to lung cancer care were identified through iterative team-based coding.

RESULTS

The 26 participants had a mean age of 62 years (SD: 8.4 years) and were majority female (62%), white (77%), and urban (85%). We identified 6 major themes: trust with providers and health systems are valued by patients; financial toxicity negatively influenced the diagnostic and treatment experience; social constraints magnified other barriers; patient self-advocacy as a facilitator of care access; provider advocacy could overcome other barriers; care coordination and good communication were important to patients.

CONCLUSIONS

We have identified several barriers and facilitators to lung cancer care at an academic center in the US. These factors need to be addressed to improve quality of care among lung cancer patients. Further work will examine our findings in a community setting to understand if our findings are generalizable to patients who do not access a tertiary cancer care center.

Fragmentation of Care in Pancreatic Cancer: Effects on Receipt of Care and Survival

BACKGROUND

The impact of fragmentation of care (FC), i.e., receipt of care at > 1 institution, on treatment of pancreatic cancer is unknown. The purpose of this study was to determine factors associated with FC in curative-intent treatment of pancreatic cancer (PDAC) patients and evaluate how FC affects survival outcomes.

METHODS

Using the National Cancer Database (NCDB), data on stage I-III PDAC patients diagnosed 2006-2016 were extracted. Multiple logistic regression analyses were performed to identify factors predictive of FC and survival.

RESULTS

Of the 20,013 patients identified, 24.1% had FC. Factors predictive of FC were stage-III tumors (odds ratio [OR] 1.36; p = 0.014), higher median-income [third quartile (OR 1.38; p = 0.006) and highest-quartile (OR 1.50; p = 0.003)], care at high-volume facility (OR 1.47; p < 0.001), and receipt of multi-modal therapy (OR 1.69; p < 0.001). In contrast, age > 80 years (OR 0.82; p = 0.018), Black (OR 0.85; p = 0.013) or Asian race (OR 0.76; p = 0.033), Charlson comorbidity-index 2 (OR 0.85; p = 0.033), treatment at non-academic facility (OR 0.87; p = 0.041), and non-private insurance were negatively predictive of FC. FC independently predicted decreased 30-day [OR 0.57; p < 0.001] and 90-day mortality [OR 0.61; p < 0.001] and improved overall survival [hazard ratio 0.91; p < 0.001].

DISCUSSION

Sociodemographic factors are significantly associated with FC in curative-intent treatment of PDAC patients. FC was found to predict improved 30-day, 90-day, and overall survival outcomes.

Care Fragmentation in Patients with Differentiated Thyroid Cancer

BACKGROUND

Among surgical patients, care fragmentation (CF) is associated with worse outcomes. However, oncologic literature documents an association between high surgical volume and improved outcomes, favoring centralized cancer-surgery centers and thus predisposing to CF in patients with surgically treated tumors. We aimed to identify features associated with CF and ascertain differences in overall survival (OS) among patients with differentiated thyroid cancer (DTC).

METHODS

The National Cancer Database was queried for DTC patients diagnosed from 2009 to 2017. Patients experienced CF if part of their treatment was performed outside of the reporting facility or an associated office. A multivariable logistic regression analysis identified independent features associated with CF. A Cox multivariable regression analysis assessed the impact of CF on OS. A Kaplan-Meier analysis compared survival differences between patients experiencing CF or unified care (UC).

RESULTS

A total of 131,620 patients were included. Among them, 70,204 (53.3%) experienced CF and 61,416 (46.7%) experienced UC. Age < 55, residing in high-income areas, and stage 3 and 4 tumors were features independently associated with CF, whereas uninsured patients were less likely to experience CF than the privately insured. The features most strongly associated with CF were treatment at highest thyroid cancer-surgery volume institutions and traveling in the top distance quartile. While patients with CF experienced minor delays in time from diagnosis to surgery, 5-year OS was improved among patients with CF compared to UC for those with Stage 1-3 disease.

CONCLUSIONS

Among patients with DTC, CF is associated with treatment at a highest thyroid cancer surgery volume facility and improved OS in a setting of minor treatment delays.

Work resumption and retention in patients with advanced cancer: Experiences and perspectives of general and occupational health care professionals

OBJECTIVE

The objectives of this study were to explore the experiences and perspectives of general and occupational health care professionals regarding work resumption and work retention of patients with advanced cancer, and to identify barriers and facilitators these professionals may encounter.

METHODS

A qualitative design was applied, and individual semistructured interviews were conducted. General and occupational health care professionals were eligible to participate if they were involved in the work participation guidance of patients with advanced cancer, and were recruited through the network of the research team. Interview data were transcribed verbatim and analysed thematically via ATLAS.ti 9.

RESULTS

Interviewees (N = 17) had various occupational backgrounds, for example, occupational physician, reintegration consultant, and general practitioner. Four main themes emerged from the data: (1) Assumptions and hesitations, (2) Patient initiates stakeholder communication, (3) Role dispersion: who is in charge of what? and (4) Experience with legislation creates opportunities.

CONCLUSION

Whereas most interviewees had positive experiences with, and/or optimistic expectations of, the work resumption and work retention of patients with advanced cancer, several barriers to the work participation guidance of these patients were identified. Suggestions for improvement include creating widespread awareness of the possibility of work participation of patients with advanced cancer and developing reintegration guidelines for advanced cancer.

New approach to implement cancer patient care: The valutazione percorso rete oncologica campana (ValPeROC)‐experience from an Italian oncology network

OBJECTIVE

The primary goal of the Campania Oncology Network (ROC) was to reduce cancer delay and care fragmentation through the establishment of cancer-specific multidisciplinary oncologic groups (GOMs) and diagnostic and therapeutic assistance paths (PDTAs).

METHODS

Five cancer centres of the ROC, with their own cancer specific GOM, were selected. In our analysis, we have focused on four neoplasms: lung, colon, ovarian and prostate cancers. The median time for pre-GOM and GOM Times was calculated for each tumour site. Univariate and multivariate logistic regressions were performed to individuate risk factors for pre-GOM and GOM Time.

RESULTS

Significant differences were observed for prostate cancer compared to other patients either for pre-GOM or GOM Times. Significant risks were found for ovarian and prostate cancers in pre-GOM time and for prostate cancer in GOM-Time.

CONCLUSIONS

This experience will produce knowledge and data to guide decision-making and to manage more effectively the challenges of fighting cancer in Campania region. The Valutazione Percorso Rete Oncologica Campana (ValPeROC) study evaluates, for the first time, the ROC activity, through the analysis of key performance indices. Pre-GOM and GOM Time represent the quality of the entire regional health system and are useful to define models, which can evaluate the performance of the ROC over time.

Improved survival of non-small cell lung cancer patients after introducing patient navigation: A retrospective cohort study with propensity score weighted historic control

OnkoNetwork is a patient navigation program established in the Moritz Kaposi General Hospital to improve the timeliness and completeness of cancer investigations and treatment. The H2020 SELFIE consortium selected OnkoNetwork as a promising integrated care initiative in Hungary and conducted a multicriteria decision analysis based on health, patient experience, and cost outcomes. In this paper, a more detailed analysis of clinical impacts is provided in the largest subgroup, non-small cell lung cancer (NSCLC) patients. A retrospective cohort study was conducted, enrolling new cancer suspect patients with subsequently confirmed NSCLC in two annual periods, before and after OnkoNetwork implementation (control and intervention cohorts, respectively). To control for selection bias and confounding, baseline balance was improved via propensity score weighting. Overall survival was analyzed in univariate and multivariate weighted Cox regression models and the effect was further characterized in a counterfactual analysis. Our analysis included 123 intervention and 173 control NSCLC patients from early to advanced stage, with significant between-cohort baseline differences. The propensity score-based weighting resulted in good baseline balance. A large survival benefit was observed in the intervention cohort, and intervention was an independent predictor of longer survival in a multivariate analysis when all baseline characteristics were included (HR = 0.63, p = 0.039). When post-baseline variables were included in the model, belonging to the intervention cohort was not an independent predictor of survival, but the survival benefit was explained by slightly better stage distribution and ECOG status at treatment initiation, together with trends for broader use of PET-CT and higher resectability rate. In conclusion, patient navigation is a valuable tool to improve cancer outcomes by facilitating more timely and complete cancer diagnostics. Contradictory evidence in the literature may be explained by common sources of bias, including the wait-time paradox and adjustment to intermediate outcomes.

The Effects of the Use of Patient-Accessible Electronic Health Record Portals on Cancer Survivors’ Health Outcomes: Cross-sectional Survey Study

Background

In the past decade, patient-accessible electronic health record (PAEHR) systems have emerged as an important tool for health management both at the hospital level and individual level. However, little is known about the effects of PAEHR portals on the survivorship of patients with chronic health conditions (eg, cancer).

Objective

This study aims to investigate the effects of the use of PAEHR portals on cancer survivors’ health outcomes and to examine the mediation pathways through patient-centered communication (PCC) and health self-efficacy.

Methods

Data for this study were derived from the Health Information National Trends Survey (HINTS 5, Cycle 4) collected from February 2020 to June 2020. This study only involved respondents who reported having been diagnosed with cancer (N=626). Descriptive analyses were performed, and the mediation models were tested using Model 6 from the SPSS macro PROCESS. Statistically significant relationships among PAEHR portal use, PCC, health self-efficacy, and physical and psychological health were examined using bootstrapping procedures. In this study, we referred to the regression coefficients generated by min-max normalization as percentage coefficients (bp). The 95% bootstrapped CIs were used with 10,000 resamplings.

Results

No positive direct associations between PAEHR portal use and cancer survivors’ health outcomes were found. The results supported the indirect relationship between PAEHR portal use and cancer survivors’ psychological health via (1) PCC (bp=0.029; β=.023, 95% CI .009-.054), and (2) PCC and health self-efficacy in sequence (bp=0.006; β=.005, 95% CI .002-.014). Besides, the indirect association between PAEHR portal use and cancer survivors’ physical health (bp=0.006; β=.004, 95% CI .002-.018) via sequential mediators of PCC and health self-efficacy was also statistically acknowledged.

Conclusions

This study offers empirical evidence about the significant role of PAEHR portals in delivering PCC, improving health self-efficacy, and ultimately contributing to cancer survivors’ physical and psychological health.

Needs assessment of cancer survivors in Alaska

Purpose

Little is known about cancer survivors’ needs in Alaska. To address this knowledge gap, the Alaska Cancer Partnership conducted a needs assessment survey; our objectives were to identify unmet needs of Alaska’s cancer survivors; identify survivor sub-populations that might benefit from targeted interventions or programming; and develop recommendations for public health and community organizations and healthcare providers for addressing cancer survivors’ unmet needs.

Methods

Cancer survivors were identified using data from the Alaska Cancer Registry. A random sample of 2,600 individuals was selected to receive the survey, which assessed unmet needs across the following domains: information needs and medical care issues; quality of life; emotional and relationship issues related to cancer diagnoses; and support services. We calculated descriptive statistics for survey responses and assessed demographic predictors of unmet needs using Poisson regression.

Results

We received 335 survey responses, for a response of 13.7%. Only 29.9% of cancer survivors expressed that all their needs were met. The most highly ranked unmet needs were as follows: help to reduce stress in life; to know doctors were coordinating care; and managing concerns about cancer coming back. After adjustment, men, adults younger than 65 at diagnosis, Alaska Native people, survivors still receiving or who had recently received care, and people who had to travel 50+ miles for most of their care had significantly greater unmet needs than their comparison groups.

Conclusion

This assessment provided some of the first information regarding the needs of Alaska’s cancer survivors. These results will be used by Alaska Cancer Partnership members across the state to inform healthcare delivery, programs, and public health messaging to support survivors.

Women with gynaecological cancer awaiting radiotherapy: Self-reported wellbeing, general psychological distress, symptom distress, sexual function, and supportive care needs

OBJECTIVE

To better serve women with gynaecological cancers, we need a sound understanding of their health, wellbeing and needs. This study sought to explore these issues in a sample of Australian women before commencing curative radiotherapy.

METHODS

We undertook a secondary analysis of baseline data from a supportive care trial (n = 311). Descriptive statistics were used to summarise responses to measures of wellbeing, general psychological distress, symptom distress, sexual function and vaginal changes, and supportive care needs. Pre-specified regression models were used to examine sources of variation in wellbeing and sexual function.

RESULTS

Women reported lower emotional, functional and physical wellbeing than population norms (all p < 0.001). The prevalence of general psychological distress was 31% (95% CI 26-36%). Distress caused by physical symptoms was typically low. Health system and information needs comprised eight of the top ten moderate-to-high supportive care needs. Most women reported no change in interest for physical contact or sex compared to pre-diagnosis, but some sexually active women (16-24%) reported smaller vaginal size, increased dryness, and more pain on intercourse. General psychological distress was a robust marker of poorer wellbeing and sexual function.

CONCLUSIONS

Before radiotherapy, a substantial minority of women with gynaecological cancers experience general psychological distress, reduced wellbeing and moderate-to-high health system and information needs. A model of comprehensive care incorporating assessment of unmet needs, general psychological distress, and sexual issues is recommended. Healthcare providers may require training to elicit and respond to a constellation of interrelated issues and access relevant services for women requiring additional support.

Implementation Strategy for Highly-Coordinated Cochlear Implant Care With Remote Programming: The Complete Cochlear Implant Care Model

OBJECTIVE

To introduce and discuss implementation strategy for the Complete Cochlear Implant Care (CCIC) model, a highly-coordinated cochlear implant (CI) care delivery model requiring a single on-site visit for preoperative workup, surgery, and postoperative programming.

STUDY DESIGN

Prospective, nonrandomized, two-arm clinical trial.

SETTING

Tertiary referral CI center.

PATIENTS

Adults who meet audiologic criteria for cochlear implantation.

INTERVENTIONS

Cochlear implantation, coordinated care delivery, including remote programming.

MAIN OUTCOME MEASURES

Care delivery model feasibility and process implementation.

RESULTS

Patients determined to be likely CI candidates based on routine audiometry are eligible for enrollment. The CCIC model uses telemedicine and electronic educational materials to prepare patients for same-day on-site consultation with CI surgery, same or next-day activation, and postoperative remote programming for 12 months. Implementation challenges include overcoming inertia related to the implementation of a new clinical workflow, whereas scalability of the CCIC model is limited by current hardware requirements for remote programming technology. A dedicated CCIC process coordinator is critical for overcoming obstacles in implementation and process improvement through feedback and iterative changes. Team and patient-facing materials are included and should be tailored to fit each unique CI program looking to implement CCIC.

CONCLUSION

The CCIC model has the potential to dramatically streamline hearing healthcare delivery. Implementation requires an adaptive approach, as obstacles may vary according to institutional infrastructure and policies.

Cancer tracking system improves timeliness of liver cancer care at a Veterans Hospital: A comparison of cohorts before and after implementation of an automated care coordination tool

INTRODUCTION

Hepatocellular carcinoma (HCC) requires complex care coordination. Patient safety may be compromised with untimely follow-up of abnormal liver imaging. This study evaluated whether an electronic case-finding and tracking system improved timeliness of HCC care.

METHODS

An electronic medical record-linked abnormal imaging identification and tracking system was implemented at a Veterans Affairs Hospital. This system reviews all liver radiology reports, generates a queue of abnormal cases for review, and maintains a queue of cancer care events with due dates and automated reminders. This is a pre-/post-intervention cohort study to evaluate whether implementation of this tracking system reduced time between HCC diagnosis and treatment and time between first liver image suspicious for HCC, specialty care, diagnosis, and treatment at a Veterans Hospital. Patients diagnosed with HCC in the 37 months before tracking system implementation were compared to patients diagnosed with HCC in the 71 months after its implementation. Linear regression was used to calculate mean change in relevant intervals of care adjusted for age, race, ethnicity, BCLC stage, and indication for first suspicious image.

RESULTS

There were 60 patients pre-intervention and 127 post-intervention. In the post-intervention group, adjusted mean time from diagnosis to treatment was 36 days shorter (p = 0.007), time from imaging to diagnosis 51 days shorter (p = 0.21), and time from imaging to treatment 87 days shorter (p = 0.05). Patients whose imaging was performed for HCC screening had the greatest improvement in time from diagnosis to treatment (63 days, p = 0.02) and from first suspicious image to treatment (179 days, p = 0.03). The post-intervention group also had a greater proportion of HCC diagnosed at earlier BCLC stages (p<0.03).

CONCLUSIONS

The tracking system improved timeliness of HCC diagnosis and treatment and may be useful for improving HCC care delivery, including in health systems already implementing HCC screening.

Patient risk screening to improve transitions of care in surgical opioid prescribing: a qualitative study of provider perspectives

Introduction

In patients undergoing surgical procedures, transitions in opioid prescribing occur across multiple providers during the months before and after surgery. These transitions often result in high-risk and uncoordinated prescribing practices, especially for surgical patients with prior opioid exposure. However, perspectives of relevant providers about screening and care coordination to address these risks are unknown.

Methods

We conducted qualitative interviews with 24 surgery, primary care, and anesthesia providers in Michigan regarding behaviors and attitudes about screening surgical patients to inform perioperative opioid prescribing in relation to transitions of care. We used an interpretive description framework to topically code interview transcripts and synthesize underlying themes in analytical memos.

Results

Providers believed that coordinated, multidisciplinary approaches to identify patients at risk of poor pain and opioid-related outcomes could improve transitions of care for surgical opioid prescribing. Anesthesia and primary care providers saw value in knowing patients’ preoperative risk related to opioid use, while surgeons’ perceptions varied widely. Across specialties, most providers favored a screening tool if coupled with actionable recommendations, sufficient resources, and facilitated coordination between specialties. Providers identified a lack of pain specialists and a dearth of actionable guidelines to direct interventions for patients at high opioid-related risk as major limitations to the value of patient screening.

Discussion

These findings provide context to address risk from prescription opioids in surgical transitions of care, which should include identifying high-risk patients, implementing a coordinated plan, and emphasizing actionable recommendations.

Black boxes and information pathways: An actor-network theory approach to breast cancer survivorship care

Many women diagnosed with breast cancer today can expect to live long after completing their treatment. This growing population of survivors encounters distinct post-treatment health and information needs. Existing survivorship care models take information as a given, black boxing it. I use Actor-Network Theory to examine how information actually works for women after they complete breast cancer treatment, and how it shapes their understanding of survivorship. I draw on in-depth interviews with breast cancer survivors (n = 82) and a wide range of providers (n = 84) in a medically underserved region of Southern California. Black boxes and information pathways convey experiential dimensions of cancer care; they are also metaphoric constructs. The black box metaphor refers to the cancer experience as a container; the pathways metaphor refers to a journey. Each of these metaphors expresses salient dimensions of the cancer experience and has implications for post-treatment survivorship. When healthcare information flows smoothly and invisibly, its pathways become black boxed. Black boxes can be helpful when they function effectively. But since black boxes conceal their inner workings, it is challenging to intervene when difficulties arise. I provide three examples of difficulties that complicate women's transition to post-treatment survivorship: (1) when survivors fail to recognize treatment-related late effects, (2) do not understand they have a terminal diagnosis, or (3) worry that their treatment accomplished nothing. Contextualized within survivorship scholarship, this study recommends opening black boxes to examine how information pathways could connect women differently to improve survivorship care.

Patient-centered Care and Integrated Practice Units: Embracing the Breast Care Continuum

Patient-centered care is a health care approach optimized for the needs of the patient. As patients have sought more autonomy in recent years, this model has been more frequently adopted. Breast radiologists aspiring to advance patient-centered care should seek greater ownership of the breast diagnostic imaging and intervention workflows, helping their patients navigate the complex breast care landscape with patients' preferences taken into account. Applying this approach to breast radiology will increase patient satisfaction and compliance while also limiting wasted health care dollars, unnecessary diagnostic delays, and overall confusion. Herein, the benefits of patient-centered breast radiology are discussed, and numerous suggestions and case examples are provided to help readers reshape their practice toward the priorities of their patients.