Patient perspectives on primary care and oncology care coordination in the context of multiple chronic conditions: A systematic review

Increasing challenges of general practitioner-oncologist interaction in end-of-life communication: a qualitative study

BACKGROUND

The timely initiation of end-of-life (EOL) conversations is considerered best practice for patients with advanced cancer and therefore recommended in oncological guidelines. General practitioners (GPs) play a key role in the coordination of EOL-care and often claim that they have also the responsibility to initiate the necessary conversations. Nonetheless, the content of these conversations is rarely a subject of communication between GPs and oncology specialists but crucial for timely integration of palliative care. The aim of this study is to explore the GPs' perspectives on initiation and conduction of EOL-conversations in patients with metastatic lung cancer and how they perceive the interaction with the oncologists of a cancer center.

METHODS

Qualitative design with in-depth interviews with GPs that refer patients with metastatic lung cancer to a cancer center; thematic analysis following Braun and Clarke.

RESULTS

We identified three main themes: timing and conduction of EOL-conversations, factors influencing EOL-conversations, and modes of GP-oncologist interaction. All themes showed important and increasing challenges in regard to communication strategies or procedures within the cancer center and between general practitioners and oncologists. Aside from the elucidated challenges of EOL-communication, new problems arise from the difficulties in keeping pace with advances in oncology and the increasing prognostic uncertainty. Additionally, the lack of standardized communication in EOL-topics between GPs and oncologists is underlined. Options in the mode of interaction include written information in reports or digital platforms and direct phone calls.

CONCLUSIONS

Because of the growing complexity in modern oncology, strategies for improvement in GP-oncologist interaction have to consider information about therapeutic advances and prognosis of patients. The increasing prognostic uncertainty hazards the adequate provision and conduction of EOL-conversations and thus, the timely integration of palliative care. As a consequence, a trustful personal interaction that includes direct contact via phone calls between GPs and oncologists should be encouraged.

[Evaluating patient experience in oncology and chronic diseases: Critical analysis of available tools (PROMs, PREMs, Satisfaction)]

Care quality assessment emerged in the late 1990s, leading to the integration of users into healthcare systems. To integrate patient perceptions, resources such as PROs (Patient Reported Outcomes), PROMs (Patient-Reported Outcome Measures), satisfaction and patient experts or partners have been developed. PREMs (Patient-Reported Experience Measures) have recently emerged, bringing a fresh perspective to improving quality and care pathways, but are still little-known. The aim of this study is to carry out a critical analysis of available publications on tools for evaluating the patient's experience of the care pathway for a chronic disease, with a focus on oncology, and to identify common themes. A literature search was carried out from June 2023 to March 2024. It focused on the concepts of quality of life, satisfaction and patient experience. Seventy-nine articles related to patient experience were identified, including 44 in oncology and 35 outside oncology. The measures analyzed include experience questions as well as satisfaction questions and/or PROMs measures. Nevertheless, they address concordant domains that are important to the patient. This study has shown a consistent development of PROMs and patient satisfaction. PROMs and patient experience are still new. Their use remains focused on targeted stages of care, and there is a lack of tools for assessing the patient's care pathway more globally.

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.

How Do People Living With Cancer Navigate Health Systems?: A Multi-Grounded Theory

BACKGROUND

Cancer and its physiological and psychological effects are well defined, but how these factors impact health system navigation for people living with cancer (PLWC) is lacking.

OBJECTIVE

To develop a theory explaining how PLWC navigate health systems to meet their health and well-being needs.

METHODS

This study used multi-grounded theory to explain how PLWC navigate health systems to meet their needs. Individuals more than 6 months postdiagnosis participated in semistructured interviews. The theory was grounded with the Health Beliefs Model and Socioecological Model to generate a candidate theory.

RESULTS

Eighteen participants were interviewed (n = 12 female); the most prominent cancer type was breast (50%). The theory comprised 5 components describing how PLWC navigate health services: (1) "being on the journey" referenced a core care team and differing utilization over time; (2) "adjusting to a new identity" addressed feeling lost and isolated and a desire to be around people who have experienced cancer; (3) "assimilating knowledge" included knowledge about cancer, timing, and source of information; (4) "navigating the health system" found health-seeking attitudes and behaviors dictated whether services were accessed; and (5) "policy environment" acknowledged how policy set the context within which all theory components exist.

CONCLUSIONS

The candidate theory depicts core factors influencing how PWLC navigate health and well-being services over their cancer journey and into survivorship.

IMPLICATIONS FOR PRACTICE

The theory identifies factors that influence access to healthcare, including trust and knowledge, which can form the basis of navigational initiatives and programs.

Patient-Physician Communication Experience Modifies Racial/Ethnic Health Care Disparities Among Surveillance, Epidemiology, and End Results-Consumer Assessment of Healthcare Providers and Systems Participants With Colorectal Cancer and Multiple Chronic Conditions

PURPOSE

After cancer diagnosis, non-White patients and those with multimorbidity use less primary care and more acute care than non-Hispanic White (NHW) patients and those lacking comorbidities. Yet, positive patient experiences with physician communication (PC) are associated with more appropriate health care use. In a multimorbid cohort, we measured associations between PC experience, race and ethnicity, and health care use following colorectal cancer (CRC) diagnosis.

PARTICIPANTS AND METHODS

We identified 2606 participants using Surveillance, Epidemiology, and End Results (SEER)-Consumer Assessment of Health Care Providers and Systems (CAHPS) data who were diagnosed with CRC from 2001 to 2017 with pre-existing chronic conditions. Self-reported PC experiences were derived from Medicare CAHPS surveys. Chronic condition care, emergency department, and hospital use following CRC diagnosis were identified from Medicare claims. Simple survey-weighted multivariable logistic regression stratified by experiences with care analyzed associations between race and ethnicity and health care use.

RESULTS

Among patients reporting excellent PC experience, non-Hispanic Black (NHB), Hispanic, and non-Hispanic Asian (NHA) patients were more likely to use sufficient chronic condition care than NHW patients (NHB: OR=1.48, 99.38% CI=1.38-1.58; Hispanic: OR=1.34, 99.38% CI=1.26-1.42; NHA: OR=2.31, 99.38% CI=2.12-2.51). NHB and NHA patients were less likely than NHW patients to visit the emergency department when reporting excellent PC experience (NHB: OR=0.66, 99.38% CI=0.63-0.69; NHA: OR=0.67, 99.38% CI=0.64-0.71). Among patients reporting excellent PC, NHB, Hispanic, and NHA patients were less likely than NHW patients to be hospitalized (NHB: OR=0.93, 99.38% CI=0.87-0.99; Hispanic: OR=0.93, 99.38% CI=0.87-0.99; NHA: OR=0.20, 99.38% CI=0.19-0.22).

CONCLUSION

Improving patient experiences with PC, particularly among older racial and ethnic minority cancer survivors with chronic conditions, may help reduce disparities in adverse healthcare use following CRC diagnosis.

Beyond Index Conditions: Applying a Multimorbidity Approach to Renal Cancer Nursing

OBJECTIVE

This article aims to describe the key components of renal cancer nursing and multimorbidity nursing, and reflects on how adopting a multimorbidity approach to renal cancer nursing can help nurses provide holistic patient care.

METHODS

This is a discussion paper drawing on relevant evidence and theory.

RESULTS

Renal cancer nurses have a highly specialised knowledge base and are able to use this expertise to deliver excellent care to people with cancer. However, lots of people with cancer have other conditions as well. Adopting a multimorbidity approach to nursing care provides a more holistic framework for care delivery.

CONCLUSIONS

Cancer nurses are ideally placed to support patients in this way, so they are able to deliver care which accounts for factors such as treatment burden and how this impacts on patients and carers.

IMPLICATIONS FOR NURSING PRACTICE

Nurses who care for people with renal cancer should view their patients through the lens of multimorbidity. This involves screening for other chronic conditions, considering polypharmacy, providing emotional support and continuity of care, and coordinating care in a way that accounts for the potentially burdensome nature of the patient's interactions with health care.

Living With and Beyond Cancer With Comorbid Conditions: Qualitative Insights to Understand Psychosocial Support Needs

INTRODUCTION

There is a pressing need to understand and explore the complex experiences and psychosocial support needs of people LWBC-CM and their informal caregivers, to inform survivorship and supportive care interventions.

METHODS

In-depth qualitative interviews were conducted with people LWBC-CM and their informal caregivers in Scotland, invited via primary care. One-to-one, face-to-face interviews were conducted with informed consent exploring experiences of symptoms, psychosocial support needs and interactions with health services. Interviews were transcribed and analysed using a thematic approach.

RESULTS

Forty-one people LWBC-CM and twenty-three informal caregivers were interviewed. Four themes were identified: the Physical and Psychological Impact of Cancer and Comorbidity, Dominant Storie-Prioritising Conditions and Making Sense of Illness, Navigating Health Services and Treatments and Caring for People with Complex Health Conditions. Type and severity of conditions mediated people's experiences and daily living. Complex fatigue-fatigue arising from a number of health conditions-dominated symptomology. Participants navigated multiple appointments and complex medication regimes. Patients identified the need for acknowledgement of other chronic conditions and for streamlined care provision. Mutual caring and social isolation were also identified as part of the caring relationship.

CONCLUSIONS

There is a mandate to address the psychosocial support needs of people LWBC-CM, and their informal carers, given the burden of treatment for cancer survivors with moderate to severe complex conditions as they navigate health services.

PATIENT OR PUBLIC CONTRIBUTION

A patient representative has been involved in all stages of the study from development of the application through study design, commenting on documentation, analysis of transcripts and writing the manuscript. They are included as an author on the manuscript.

Health Care Use Among Cancer Patients With Diabetes, National Health and Nutrition Examination Survey, 2017-2020

Introduction

Diabetes is a common comorbidity among people with cancer. The objective of our study was to examine patterns of health care use among patients with cancer and either type 2 diabetes or prediabetes.

Methods

We used data from the National Health and Nutrition Examination Survey (NHANES) for 2017-2020. The study population included US adults aged 18 years or older who were diagnosed with any cancer and type 2 diabetes or prediabetes (established by self-report and/or hemoglobin A1c measurement). We used Poisson and multivariate logistic regression models to determine the effect of comorbidity on health care use, defined as health care visits and overnight stays in a hospital.

Results

Of 905 cancer patients representing 27,180,715 people in the US, 24.4% had a type 2 diabetes diagnosis, and 25.8% had a prediabetes diagnosis. Patients with cancer and prediabetes had a significantly higher rate of health care visits (incidence rate ratio = 1.11; 95% CI, 1.01-1.22; P = .03) than patients with cancer only. We found no significant association between having cancer and type 2 diabetes and the number of health care visits or overnight hospital stays compared with patients with cancer only.

Conclusion

More emphasis should be placed on optimal care coordination among people with cancer and other conditions, such as diabetes and prediabetes, to reduce the impact of comorbidity on health care use. Interventions integrated with technology to provide timely access to education on preventing or managing diabetes and prediabetes among cancer patients are warranted.

Content validity of patient-reported measures evaluating experiences of the quality of transitions in healthcare settings-a scoping review

No reviews so far have been conducted to define the constructs of patient-experienced quality in healthcare transitions or to identify existing generic measures of patients' experience of the quality within healthcare transitions. Our aim was to identify domains relevant for people experiencing healthcare transitions when evaluating the quality of care they have received, map the comprehensiveness of existing patient-reported experience measures (PREM), and evaluate the PREMs' content validity. The method was guided by the Joanna Briggs Institutes' guidance for scoping reviews. The search was performed on 07 December 2021 and updated 27 May 2024, in the electronic databases Medline (Ovid), Embase (Ovid), and Cinahl (EBSCO). The search identified 20,422 publications, and 190 studies were included for review. We identified 30 PREMs assessing at least one aspect of adults' experience of transitions in healthcare. Summarising the content, we consider a model with two domains, organisational and human-relational, likely to be adequate. However, a more comprehensive analysis and adequate definition of the construct is needed. None of the PREMs were considered content valid.

Patient Experiences and Perceptions of Care Coordination in Primary Care

BACKGROUND

Understanding patient perceptions of care coordination in primary care can help improve responsiveness to patients' needs, outcomes, and quality of care.

PURPOSE

The purpose of this study was to explore patient experiences and perceptions of care coordination in primary care.

METHOD

Interviews with 13 patients from 10 clinics were conducted and analyzed using directed content analysis.

RESULTS

Three primary themes arose: care coordinators provide a gateway to accessing needed care; patients needed and valued the support and trusted advice of their care coordinators; and patients valued care coordinators' help with navigating, engaging, and educating them about their care.

CONCLUSIONS

Understanding what patients value in care delivery can help frame a vision for a more responsive approach in delivering primary care, as well as create a pathway to quality improvement, moving toward a truly patient-centered focus in primary care.

Exploring the impact of primary care utilization and health information exchange upon treatment patterns and clinical outcomes of glioblastoma patients

PURPOSE

There is limited literature describing care coordination for patients with glioblastoma (GBM). We aimed to investigate the impact of primary care and electronic health information exchange (HIE) between neurosurgeons, oncologists, and primary care providers (PCP) on GBM treatment patterns, postoperative outcomes, and survival.

METHODS

We identified adult GBM patients undergoing primary resection at our institution (2007-2020). HIE was defined as shared electronic medical information between PCPs, oncologists, and neurosurgeons. Multivariate logistic regression analyses were used to determine the effect of PCPs and HIE upon initiation and completion of adjuvant therapy. Kaplan-Meier and multivariate Cox regression models were used to evaluate overall survival (OS).

RESULTS

Among 374 patients (mean age ± SD: 57.7 ± 13.5, 39.0% female), 81.0% had a PCP and 62.4% had electronic HIE. In multivariate analyses, having a PCP was associated with initiation (OR: 7.9, P < 0.001) and completion (OR: 4.4, P < 0.001) of 6 weeks of concomitant chemoradiation, as well as initiation (OR: 4.0, P < 0.001) and completion (OR: 3.0, P = 0.007) of 6 cycles of maintenance temozolomide thereafter. Having a PCP (median OS [95%CI]: 14.6[13.1-16.1] vs. 10.8[8.2-13.3] months, P = 0.005) and HIE (15.40[12.82-17.98] vs. 13.80[12.51-15.09] months, P = 0.029) were associated with improved OS relative to counterparts in Kaplan-Meier analysis and in multivariate Cox regression analysis (hazard ratio [HR] = 0.7, [95% CI] 0.5-1.0, P = 0.048). In multivariate analyses, chemoradiation (HR = 0.34, [95% CI] 0.2-0.7, P = 0.002) and maintenance temozolomide (HR = 0.5, 95%CI 0.3-0.8, P = 0.002) were associated with improved OS relative to counterparts.

CONCLUSION

Effective care coordination between neurosurgeons, oncologists, and PCPs may offer a modifiable avenue to improve GBM outcomes.

Quality in care requires kindness and flexibility - a hermeneutic-phenomenological study of patients' experiences from pathways including transitions across healthcare settings

BACKGROUND

The number of people living with chronic conditions is increasing worldwide, and with that, the need for multiple long-term complex care across care settings. Undergoing transitions across healthcare settings is both challenging and perilous for patients. Nevertheless, knowledge of what facilitates quality during transitions in healthcare settings from the lifeworld perspective of patients is still lacking. Therefore, we aimed to explore the lived experience in healthcare quality for Danish adult patients during healthcare pathways including transitions across settings.

METHODS

Within a hermeneutic-phenomenological approach, interviews were conducted with three women and five men with various diagnoses and care paths between 30 and 75 years of age. Data underwent a three phased thematic analysis leading to three themes.

RESULTS

Patients with various illnesses' experiences of quality of care is described in the themes being powerless in the face of illness; burdensome access and navigation; and being in need of mercy and striving for kindness. This highlights that patients' experiences of quality in healthcare pathways across settings interweaves with an overall understanding of being powerless at the initial encounter. Access and navigation are burdensome, and system inflexibility adds to the burden and enhances powerlessness. However, caring care provided through the kindness of healthcare professionals supports patients in regaining control of their condition.

CONCLUSIONS

This hermeneutical-phenomenological study sheds light on the lived experiences of people who are at various stages in their care paths with transitions across healthcare settings. Although our findings are based on the lived experiences of 8 people in a Danish context, in light of the discussion with nursing theory and other research, the results can be reflected in two main aspects: I) kind and merciful professional relationships and II) system flexibility including access and navigation, were essential for their experiences of care quality during healthcare transitions. This is important knowledge when striving to provide patients with a clear voice regarding quality in care pathways stretching across settings.

Caring for high-need patients

OBJECTIVE

We aimed to explore the construct of "high need" and identify common need domains among high-need patients, their care professionals, and healthcare organizations; and to describe the interventions that health care systems use to address these needs, including exploring the potential unintended consequences of interventions.

METHODS

We conducted a modified Delphi panel informed by an environmental scan. Expert stakeholders included patients, interdisciplinary healthcare practitioners (physicians, social workers, peer navigators), implementation scientists, and policy makers. The environmental scan used a rapid literature review and semi-structured interviews with key informants who provide healthcare for high-need patients. We convened a day-long virtual panel meeting, preceded and followed by online surveys to establish consensus.

RESULTS

The environmental scan identified 46 systematic reviews on high-need patients, 19 empirical studies documenting needs, 14 intervention taxonomies, and 9 studies providing construct validity for the concept "high need." Panelists explored the construct and terminology and established that individual patients' needs are unique, but areas of commonality exist across all high-need patients. Panelists agreed on 11 domains describing patient (e.g., social circumstances), 5 care professional (e.g., communication), and 8 organizational (e.g., staffing arrangements) needs. Panelists developed a taxonomy of interventions with 15 categories (e.g., care navigation, care coordination, identification and monitoring) directed at patients, care professionals, or the organization. The project identified potentially unintended consequences of interventions for high-need patients, including high costs incurred for patients, increased time and effort for care professionals, and identification of needs without resources to respond appropriately.

CONCLUSIONS

Care for high-need patients requires a thoughtful approach; differentiating need domains provides multiple entry points for interventions directed at patients, care professionals, and organizations. Implementation efforts should consider outlined intended and unintended downstream effects on patients, care professionals, and organizations.

Patient navigation across the cancer care continuum: An overview of systematic reviews and emerging literature

Patient navigation is a strategy for overcoming barriers to reduce disparities and to improve access and outcomes. The aim of this umbrella review was to identify, critically appraise, synthesize, and present the best available evidence to inform policy and planning regarding patient navigation across the cancer continuum. Systematic reviews examining navigation in cancer care were identified in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Cumulative Index of Nursing and Allied Health (CINAHL), Epistemonikos, and Prospective Register of Systematic Reviews (PROSPERO) databases and in the gray literature from January 1, 2012, to April 19, 2022. Data were screened, extracted, and appraised independently by two authors. The JBI Critical Appraisal Checklist for Systematic Review and Research Syntheses was used for quality appraisal. Emerging literature up to May 25, 2022, was also explored to capture primary research published beyond the coverage of included systematic reviews. Of the 2062 unique records identified, 61 systematic reviews were included. Fifty-four reviews were quantitative or mixed-methods reviews, reporting on the effectiveness of cancer patient navigation, including 12 reviews reporting costs or cost-effectiveness outcomes. Seven qualitative reviews explored navigation needs, barriers, and experiences. In addition, 53 primary studies published since 2021 were included. Patient navigation is effective in improving participation in cancer screening and reducing the time from screening to diagnosis and from diagnosis to treatment initiation. Emerging evidence suggests that patient navigation improves quality of life and patient satisfaction with care in the survivorship phase and reduces hospital readmission in the active treatment and survivorship care phases. Palliative care data were extremely limited. Economic evaluations from the United States suggest the potential cost-effectiveness of navigation in screening programs.

"Care needs to be integrated" Patient and provider perspectives on a cancer shared-care model

PURPOSE

Current early-stage breast and gynecological cancer care models often begin with a referral from a primary care provider (PCP) or gynecologist (OB/Gyn) and end with a patient being transitioned back to the referring provider at the completion of treatment. There is frequently little communication between oncologists and the referring provider during treatment, and this pattern continues after the patient completes their treatment.

METHODS

We convened a diverse Patient Advisory Board (PAB) to identify areas where breast or gynecological cancer patients felt they could benefit from additional support during and after their cancer care. PAB members attended five Zoom meetings and completed four online surveys. Semi-structured interviews were conducted with primary care or OB/Gyn physicians to collect information on current practices.

RESULTS

Patients identified multiple areas in which they needed additional support from their PCP. Providers also identified topics on which they could use additional training. However, there was little overlap between patient and provider priority topics. Both patients and providers agreed that there was inadequate communication between the cancer center and PCPs before, during, and after cancer treatment.

CONCLUSIONS

A shared-care model that emphasizes communication between primary care providers, the oncology care team, and patients is urgently needed. Patients indicated the need for additional support from their PCP on specific topics, and PCPs were interested in continuing their education to better serve their patients with cancer.

IMPLICATIONS FOR CANCER SURVIVORS

The importance of consistent communication among all parties during the entire cancer journey was emphasized as a key area for improvement.

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.

We Cannot Put This Genie Back in the Bottle: Qualitative Interview Study Among Family Medicine Providers About Their Experiences With Virtual Visits During the COVID-19 Pandemic

BACKGROUND

When a genie is freed from its bottle, things cannot be restored to the way they were before. At the beginning of the global COVID-19 pandemic, health care systems adjusted how they delivered care overnight. Primary care practices switched from seeing patients in person to virtual care applications, including video and phone visits, e-visits, e-consults, and messaging with clinicians. Prior to the pandemic, these applications were not as widely used, but discussions around their advantages and disadvantages in some settings were being explored. Emergency regulatory changes spurred by the pandemic freed this virtual care "genie" from its bottle. Wide-scale adoption of virtual care in family medicine has much potential, as primary care services are often a patient's first point of contact with the health care system.

OBJECTIVE

This study aims to analyze family medicine providers' experiences using virtual visits during the pandemic, perceived outcomes of the shift to virtual visits, and discusses its implications for the future of family medicine.

METHODS

This qualitative study took place at 3 academic primary care clinics between June and December 2020. Data were collected through one-on-one Zoom (version 5.2.1) interviews with family medicine clinical faculty who experienced the rapid transition of in-person visits to mostly "virtual" visits. The interviews were recorded, deidentified, and transcribed. We adopted a constructivist approach to qualitative content analysis to evaluate the results.

RESULTS

In total, 25 participants were eligible, and 20 individuals participated in this study (80% participation rate). The mean age was 43.4 years, and 85% (17/20) of the participants were female. We identified 3 main themes: the care process, patient engagement, and team-based care.

CONCLUSIONS

This study highlights the transition from in-person to virtual visits during the pandemic from the perspective of family medicine providers. Generally, family medicine providers' perceptions of the shift to virtual visits were positive, especially regarding team-based care. Challenges involved virtual inhibition, particularly for providers. Providers described ways they integrated virtual care with aspects of in-person care, creating a hybrid environment. The genie is out of the bottle-things will not be the same-but family medicine now has the opportunity to evolve.

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.

Patient perspectives on primary care for multimorbidity: An integrative review

INTRODUCTION

Improving healthcare for people with multiple chronic or ongoing conditions is receiving increased attention, particularly due to the growing number of people experiencing multimorbidity (MM) and concerns about the sustainability of the healthcare system. Primary care has been promoted as an important resource for supporting people with MM to live well with their conditions and to prevent unnecessary use of health care services. However, traditional primary care has been criticized for not centring the needs and preferences of people with MM themselves. Our aim was to conduct a review that centred on the perspective of people with MM in multiple ways, including having patient partners co-lead the design, conduct and reporting of findings, and focusing on literature that reported the perspective of people with MM, irrespective of it being experimental or nonexperimental.

METHODS

We searched for published literature in CINAHL with Full Text (EBSCOhost) and MEDLINE All (Ovid). Findings from experimental and nonexperimental studies were integrated into collaboration with patient partners.

RESULTS

Twenty-nine articles were included in the review. Findings are described in five categories: (1) Care that is tailored to my unique situation; (2) meaningful inclusion in the team; (3) a healthcare team that is ready and able to address my complex needs; (4) supportive relationships and (5) access when and where I need it.

CONCLUSION

This review supports a reorientation of primary care systems to better reflect the experiences and perspectives of people with MM. This can be accomplished by involving patient partners in the design and evaluation of primary care services and incentivizing collaboration among health and social supports and services for people with MM.

PATIENT OR PUBLIC CONTRIBUTION

Patient partners were involved in the design and conduct of this review, and in the preparation of the manuscript. Their involvement is further elucidated in the manuscript text.

Managing diabetes during treatment for breast cancer: oncology and primary care providers' views on barriers and facilitators

Purpose

Diabetes is a prevalent comorbid condition among many women with breast cancer. The roles and responsibilities of managing diabetes during cancer care are unclear, as oncologists lack interest and clinical expertise and many patients stop seeing their primary care providers (PCPs). Uncertainty around who should manage diabetes for cancer patients can result in gaps in care for survivors. We sought to elicit the perspectives of providers about a novel diabetes care delivery intervention for women undergoing chemotherapy for breast cancer.

Methods

We conducted nominal group sessions with PCPs and breast oncologists across the USA. We introduced a novel care delivery model, which involved a nurse practitioner (NP) specifically trained in diabetes to work within the oncology team to manage diabetes for women during chemotherapy. PCPs and oncologists were asked to identify potential barriers and facilitators to the intervention’s success and then vote on the top three most important barriers and facilitators, separately. Votes were aggregated across sessions and presented as frequencies and weighted percentages.

Results

From November to December 2020, two 60-min sessions with PCPs and two 60-min sessions with breast oncologists were held virtually. In total, 29 providers participated, with 16 PCPs and 13 breast oncologists. At the health system level, financial support for the NP-led intervention was identified as the most important barrier across both provider types. Clearly defined roles for each care team member were identified as the most important facilitator at the care team level. At the patient level, lack of cancer-specific diabetes education was identified as an important barrier.

Conclusion

Our findings underscore the need to engage various stakeholders including policy makers, institutional leadership, care team members, and patients to improve diabetes care for patients undergoing chemotherapy for breast cancer. As such, multi-disciplinary interventions are warranted to increase awareness, engagement, and self-management practices among breast cancer patients with diabetes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-022-07112-4.

Understanding the Attitudes and Beliefs of Oncologists Regarding the Transitioning and Sharing of Survivorship Care

Transitioning survivorship care from oncologists to primary care physicians (PCPs) is a reasonable alternative to oncologist-led care. This study assessed oncologists’ attitudes and beliefs regarding sharing/transitioning survivorship care. A prospective survey of oncologists within a regional cancer program assessing self-reported barriers and facilitators to sharing/transitioning survivorship care was disseminated. In total, 63% (n = 39) of surveyed oncologists responded. Patient preference (89%) and anxiety (84%) are key to transition of care decisions; reduced remuneration (95%) and fewer longitudinal relationships (63%) do not contribute. Oncologists agreed that more patients could be shared/transitioned. Barriers include treatment-related toxicities (82% agree), tumor-specific factors (60–90% agree) and perception of PCP willingness to participate in survivorship care (47% agree). Oncologists appear willing to share/transition more survivors to PCPs, though barriers exist that warrant further study. Understanding these issues is critical to developing policies supporting comprehensive survivorship care models that address both cancer and non-cancer health needs. The demonstrated feasibility of this project warrants a larger-scale survey of oncologists with respect to the transition of survivorship care to PCPs, to further inform effective interventions to support high-quality survivorship care.

Challenges adopting next-generation sequencing in community oncology practice

PURPOSE OF REVIEW

We are in an exhilarating time in which innovations exist to help reduce the impact of cancer for individuals, practitioners and society. Innovative tools in cancer genomics can optimize decision-making concerning appropriate drugs (alone or in combination) to cure or prolong life. The genomic characterization of tumours can also give direction to the development of novel drugs. Next-generation tumour sequencing is increasingly becoming an essential part of clinical decision-making, and, as such, will require appropriate coordination for effective adoption and delivery.

RECENT FINDINGS

There are several challenges that will need to be addressed if we are to facilitate cancer genomics as part of routine community oncology practice. Recent research into this novel testing paradigm has demonstrated the barriers are at the individual level, while others are at the institution and societal levels.

SUMMARY

This article, based on the authors' experience in community oncology practice and summary of literature, describes these challenges so strategies can be developed to address these challenges to improve patient outcomes.

Patient's treatment burden related to care coordination in the field of respiratory diseases

The management of respiratory diseases requires various levels of care: multidisciplinary teams, educational and behavioural interventions, self-management and home-based technical support are vital to ensure adequate care management. However, it is often difficult to access these networks due to fragmentation of patient care and treatment burden. Care coordination aims to ensure patients have a central role and that there is continuity of care among various levels and professionals involved. Moreover, the coronavirus disease pandemic has caused strain on the global healthcare system, with care coordination becoming increasingly important in increasing the resilience of health systems, supporting healthcare professionals and ensuring the right treatment and adequate level of care for these patients.

Impact of provider type and number of providers on surveillance testing among survivors of head and neck cancers

BACKGROUND

Guidelines for follow-up after head and neck cancer (HNC) treatment recommend frequent clinical examinations and surveillance testing. Here, the authors describe real-world follow-up care for HNC survivors and variations in surveillance testing.

METHODS

Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, this study examined a population-based cohort of HNC survivors between 2001 and 2011 Usage of cross-sectional head and neck imaging (CHNI), chest imaging (CI), positron emission tomography (PET), fiberoptic nasopharyngolaryngoscopy (FNPL), and, in irradiated patients, thyroid function testing (TFT) was captured over 2 consecutive surveillance years. Multivariate modeling with logistic regression analyses was used to assess variations by clinical factors, nonclinical factors, number and types of providers seen and their evolution over time.

RESULTS

Among 13,836 HNC survivors, the majority saw a medical, radiation, or surgical oncologist and a primary care provider (PCP; 81.7%) in their first year of surveillance. However, only 58.1% underwent either PET or CHNI, 47.8% underwent CHNI, 64.1% underwent CI, 32.5% underwent PET scans, 55.0% underwent FNPL, and 55.9% underwent TFT. In multivariate analyses, patients who followed up with more providers and those who followed up with both a PCP and an oncologist were more likely to undergo surveillance testing (P < .007). However, adjusting for providers seen did not explain the variations in surveillance testing rates based on age, race, education, income level, and place of residence. Over time, there was a gradual increase in the use of PET scans and TFT during surveillance years.

CONCLUSIONS

In this large SEER-Medicare data study, only half of HNC survivors received the recommended testing, and greater compliance was seen in those who followed up with both an oncologist and a PCP. More attention is needed to minimize variations in surveillance testing across sociodemographic groups.