Deliberative stakeholder consultations: creating insights into effective practice-change in family medicine

Risk-Stratified Pathways for Cancer Survivorship Care: Insights from a Deliberative Multi-Stakeholder Consultation

Risk-stratified pathways of survivorship care seek to optimize coordination between cancer specialists and primary care physicians based on the whole person needs of the individual. While the principle is supported by leading cancer institutions, translating knowledge to practice confronts a lack of clarity about the meaning of risk stratification, uncertainties around the expectations the model holds for different actors, and health system structures that impede communication and coordination across the care continuum. These barriers must be better understood and addressed to pave the way for future implementation. Recognizing that an innovation is more likely to be adopted when user experience is incorporated into the planning process, a deliberative consultation was held as a preliminary step to developing a pilot project of risk-stratified pathways for patients transitioning from specialized oncology teams to primary care providers. This article presents findings from the deliberative consultation that sought to understand the perspectives of cancer specialists, primary care physicians, oncology nurses, allied professionals, cancer survivors and researchers regarding the following questions: what does a risk stratified model of cancer survivorship care mean to care providers and users? What are the prerequisites for translating risk stratification into practice? What challenges are involved in establishing these prerequisites? The multi-stakeholder consultation provides empirical data to guide actions that support the development of risk-stratified pathways to coordinate survivorship care.

Communication of Pharmacogenomic test results and treatment plans in pediatric oncology: deliberative stakeholder consultations with parents

Background

Effective communication in support of clinical decision-making is central to the pediatric cancer care experience for families. A new laboratory derived pharmacogenetic test (LDT) that can diagnose difficult-to-treat brain cancers has been developed to stratify children based on their ability to respond to available treatment; however, the potential implementation of the LDT may make effective communication challenging since it can potentially remove the option for curative treatment in those children identified as non-responders, i.e. those with a catastrophic diagnosis.

Objective

We solicited the perspectives of parents of children with difficult-to-treat brain cancer on communication preferences surrounding the potential implementation of the LDT in standard care using deliberative stakeholder consultations.

Methods

Eight bereaved parents of children who succumbed to difficult-to-treat brain cancer, and four parents of children currently undergoing treatment for similar cancers attended separate small-group deliberative consultations – a stakeholder engagement method that enables the co-creation of recommendations following the consideration of competing arguments and diverse opinions of parents with different experiences. In the small-group consultations (Phase I), parents discussed four questions about potential communication issues that may arise with the LDT in practice. In Phase II, a total of five parents from both stakeholder groups (4 bereaved and 1 in current treatment) attended a consultation, known as the ‘mixed’ consultation, with the purpose of co-developing concrete recommendations for implementation of the LDT.

Results

Explaining the risks, benefits, and accuracy of the LDT were considered essential to parents. Once an LDT-based diagnosis/prognosis can be made, parents valued honesty, empathy, and clarity in communication. Parents also requested that all results and treatment options be presented to them in measured doses, and in an unbiased manner over the course of several meetings. This communication strategy allowed sufficient time to understand and accept the diagnosis/prognosis, particularly if it was catastrophic. Continuous access to the appropriate psychological and social support or counselling at and post-diagnosis was also strongly recommended.

Conclusions

Deliberants co-created family-centered recommendations surrounding communication issues of the LDT, providing guidance to pediatric oncologists that could implement the test in practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00709-2.

Understanding how professionals cultures impact implementation of a pediatric oncology genomic test

Purpose

Healthcare innovation, exemplified by genomic medicine, requires increasingly sophisticated understanding of the interdisciplinary-organizational context in which new innovations are implemented. Deliberative stakeholder consultations are public engagement tools that are gaining increasing traction in health care, as a means of maximizing the diversity of roles and interests vested in a particular policy or practice issue. They engage participants from different knowledge systems (“cultures”) in mutually respectful debate to enable group consensus on implementation strategies. Current deliberation analytic methods tend to overlook the cultural contexts of the deliberative process. The paper aims to discuss this issue.

Design/methodology/approach

This conceptual paper proposes adding ethnographic participant observation to provide a more comprehensive account of the process that gives rise to deliberative outputs. To underpin this conceptual paper, the authors draw on the authors’ experience engaging healthcare professionals during implementation of genomics in the care for pediatric oncology patients with treatment-resistant glioblastoma at two tertiary care hospitals.

Findings

Ethnography enabled a deeper understanding of deliberative outcomes by combining rhetorical and non-rhetorical analysis to identify the implementation and coordination of care barriers across professional cultures.

Originality/value

This paper highlights the value of ethnographic methods in enabling a more comprehensive assessment of the quality of engagement across professional cultures in implementation studies.

Health professionals' perspectives on breast cancer risk stratification: understanding evaluation of risk versus screening for disease

BACKGROUND

Younger women at higher-than-population-average risk for breast cancer may benefit from starting screening earlier than presently recommended by the guidelines. The Personalized Risk Stratification for Prevention and Early Detection of Breast Cancer (PERSPECTIVE) approach aims to improve the prevention of breast cancer through differential screening recommendations based on a personal risk estimate. In our study, we used deliberative stakeholder consultations to engage health professionals in an in-depth dialog to explore the feasibility of the proposed implementation strategies for this new personalized breast cancer screening approach.

METHODS

Deliberative stakeholder consultation is a qualitative descriptive study design used to engage health professionals in the discussion, while the mediators play a more passive role. A purposeful sample of 11 health professionals (family physicians and genetic counselors) working in Montreal was used. The deliberations were organized in two phases, including small group deliberations according to the deliberants' health profession and a mixed group deliberation combining participants from the small groups. Inductive thematic content analysis was performed on the transcripts by two coders to create the deliberative and analytic outputs. Quality of deliberations was assessed quantitatively using the de Vries method and qualitatively using participant observation.

RESULTS

One of our key findings was that health professionals lacked understanding of the two steps of the screening approach: risk stratification "screening," which is an evaluation for the level of risk and screening for disease. As part of this confusion, the main topic of concern was a justification of program implementation as a population-wide screening, based on their uncertainty that it will be beneficial for women with near-population risks. Despite the noted difficulties concerning implementation, health professionals acknowledged the substantial benefits of the proposed PERSPECTIVE program.

CONCLUSIONS

Our study was the first to evaluate the perspectives of health professionals on the implementation and benefits of a new program for breast cancer risk stratification with the purpose of personalizing screening for disease. This new multi-step approach to screening requires more clarity in communication with health professionals. To implement and maintain effective screening, engagement of family physicians with other health professionals or even development of a centralized public health system may be needed.