The interface of primary and oncology specialty care: from symptoms to diagnosis

Availability of cancer care services and the organization of care delivery at critical access hospitals

INTRODUCTION

Critical access hospitals (CAHs) provide an opportunity to meet the needs of individuals with cancer in rural areas. Two common innovative care delivery methods include the use of traveling oncologists and teleoncology. It is important to understand the availability and organization of cancer care services in CAHs due to the growing population with cancer and expected declines in oncology workforce in rural areas.

METHODS

Stratified random sampling was used to generate a sample of 50 CAHs from each of the four U.S. Census Bureau-designated regions resulting in a total sample of 200 facilities. Analyses were conducted from 135 CAH respondents to understand the availability of cancer care services and organization of cancer care across CAHs.

RESULTS

Almost all CAHs (95%) provided at least one cancer screening or diagnostic service. Forty-six percent of CAHs reported providing at least one component of cancer treatment (chemotherapy, radiation, or surgery) at their facility. CAHs that offered cancer treatment reported a wide range of health care staff involvement, including 34% of respondents reporting involvement of a local oncologist, 38% reporting involvement of a visiting oncologist, and 28% reporting involvement of a non-local oncologist using telemedicine.

CONCLUSION

Growing disparities within rural areas emphasize the importance of ensuring access to timely screening and guideline-recommended treatment for cancer in rural communities. These data demonstrated that CAHs are addressing the growing need through a variety of approaches including the use of innovative models that utilize non-local providers and telemedicine to expand access to crucial services for rural residents with cancer.

Cancer Care Continuum Research and Educational Innovation: Are Academic Internists Keeping up with Population Trends?

Academic internists play a unique role in conducting innovative research, developing educational curricula, and influencing policy. As the population of patients living with and beyond cancer is expected to reach 22 million by 2030, it is essential for academic internists to lead innovative research in clinical care and medical education across the cancer care continuum. We characterized cancer-related topics presented at the 2015-2019 annual meetings of the Society of General Internal Medicine, a national organization of over 3,000 academic general internists. We analyzed all scientific (n = 3,437), Innovation in Medical Education (n = 756), and Innovation in Clinical Practice (n = 664) abstracts for content across the cancer continuum: prevention, screening, diagnosis, treatment, survivorship, and palliative/end-of-life care (P/EOL). Of 3,437 scientific abstracts, 304 (8.8%) related to cancer. Prevention, screening, diagnosis, treatment, survivorship, and P/EOL were addressed in 52 (17.1%), 145 (47.7%), 18 (5.9%), 57 (18.8%), 12 (4.0%), and 29 (9.5%) of scientific abstracts, respectively. Some addressed multiple phases, and 6 were classified as "other." Breast (mean = 18.2, SD = 4.66), colorectal (mean = 12.8, SD = 3.11), and lung (mean = 8.2, SD = 2.29) cancers were most presented in scientific abstracts per year. Five (0.66%) of the 756 Innovation in Medical Education abstracts and 41 (6.2%) of the 665 Innovation in Clinical Practice abstracts addressed cancer. Similarly, they primarily focused on screening and prevention. To lead innovation in clinical care, education, and policy across the cancer continuum and prepare the future workforce, academic internists should expand their focus to later phases, particularly survivorship and P/EOL.

Assessing the implementation fidelity of HPV self-collection offered by community health workers during home visits (the EMA strategy): a case study in a low-middle-resource setting in Argentina

BACKGROUND

In Argentina, HPV  self-collection offered by community health workers was demonstrated to be effective to improve cervical cancer screening uptake. Based on these findings, the EMA strategy was scaled up in nine Argentinian provinces. However, there is no evidence about the degree of fidelity-in relation to the core components proposed by the National Program on Cervical Cancer Prevention-with which this strategy was implemented in the new jurisdictions. We carried out a fidelity evaluation of the EMA strategy scaling-up aimed at evaluating the level of adherence to the core components of the EMA strategy, and how different moderating factors affected the implementation fidelity.

METHODS

This descriptive study used a multi-method approach involving quantitative and qualitative evaluations of the implementation fidelity using the Conceptual Framework for Implementation Fidelity. Evaluation of the degree of adherence to the core components of the EMA strategy was carried out through the analysis of a self-administered survey of health promoters, observations, and secondary data from the National Screening Information System. The analysis of moderating factors was carried out through analysis of field notes, and semi-structured interviews with key stakeholders.

RESULTS

Our results showed that the core components with highest fidelity were training, sample handling, and transportation. Regarding the offer of HPV self-collection, we found some adaptations such as locations in which health promoters offered HPV self-collection, and fewer pieces of information provided to women during the offer. In the follow-up and treatment core component, we found a reduced adherence to triage and colposcopy. Some contextual factors had a negative impact on implementation fidelity, such as urban insecurity and the reduction in the number of health promoters that offered HPV self-collection. Moderating factors that contributed to achieve high level of fidelity included a well-defined strategy with clear steps to follow, permanent feedback and high level of engagement among implementers.

CONCLUSIONS

Our study shows how the analysis of fidelity and adaptations of HPV self-collection in real-world contexts are key to measure and maximize its effectiveness in low-middle-income settings.

A Learning Health System Approach to Cancer Survivorship Care Among LGBTQ+ Communities

PURPOSE

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) individuals who receive primary care services at community health centers are often referred to external specialty care centers after cancer diagnosis, upon which primary care services are disrupted and may be discontinued because of gaps in communication between primary and oncologic care providers. This qualitative study evaluated barriers and facilitators to effective care coordination for LGBTQ+ patients with cancer and the utility of a novel cancer care coordination tool to mitigate identified barriers.

MATERIALS AND METHODS

Semistructured interviews with LGBTQ+ cancer survivors, caregivers to LGBTQ+ persons, clinical team members who provide care to LGBTQ+ patients, and members of community-based organizations that work with LGBTQ+ patients were conducted. Interview analysis was a multistage process, wherein a constant comparison approach was used. Transcripts were reviewed and coded using Atlas.ti Cloud.

RESULTS

A total of 26 individuals were interviewed: 10 patients, four caregivers, 10 clinical care team members, and two community organization representatives. Interview analysis yielded insight regarding (1) LGBTQ+ patient experiences engaging with primary and oncologic care at the clinic level and (2) perceptions of patient-provider and provider-provider communication and coordination.

CONCLUSION

Interview findings indicate a need for further development of interventions aimed at improving care coordination, patient experience, and outcomes in the cancer care continuum for LGBTQ+ patients. Learning health systems, like the one studied, show great potential for contributing to the development of such interventions.

A Bibliometric Analysis and Visualization of Decision Support Systems for Healthcare Referral Strategies

BACKGROUND

The referral process is an important research focus because of the potential consequences of delays, especially for patients with serious medical conditions that need immediate care, such as those with metastatic cancer. Thus, a systematic literature review of recent and influential manuscripts is critical to understanding the current methods and future directions in order to improve the referral process.

METHODS

A hybrid bibliometric-structured review was conducted using both quantitative and qualitative methodologies. Searches were conducted of three databases, Web of Science, Scopus, and PubMed, in addition to the references from the eligible papers. The papers were considered to be eligible if they were relevant English articles or reviews that were published from January 2010 to June 2021. The searches were conducted using three groups of keywords, and bibliometric analysis was performed, followed by content analysis.

RESULTS

A total of 163 papers that were published in impactful journals between January 2010 and June 2021 were selected. These papers were then reviewed, analyzed, and categorized as follows: descriptive analysis (n = 77), cause and effect (n = 12), interventions (n = 50), and quality management (n = 24). Six future research directions were identified.

CONCLUSIONS

Minimal attention was given to the study of the primary referral of blood cancer cases versus those with solid cancer types, which is a gap that future studies should address. More research is needed in order to optimize the referral process, specifically for suspected hematological cancer patients.

Oncology and Primary Care Provider Views on Cancer Survivorship Care: Mind the Gap

CONTEXT

Coordination between oncology and primary care practices in cancer survivorship is lacking.

OBJECTIVE

To identify cancer care coordination perceptions, knowledge, and practices in a sample of Oklahoma oncology care providers (ONCs) and primary care providers (PCPs) regarding post-treatment care of adult cancer survivors.

DESIGN

Cross-sectional, statewide survey by mail/web link in 2014/5.

SETTING

PCPs identified through a primary care research network, primary care organization membership lists; ONCs identified through www.Healthgrades.com.

PARTICIPANTS

Contacts who were clinically active and seeing cancer patients were eligible. The final sample size included 101 ONCs and 58 PCPs who reported actively seeing cancer patients.

MEASURES

Responses to predominately Likert scale or ranked-order questions derived from the Survey of Physician Attitudes Regarding the Care of Cancer Survivors.

ANALYSES

Chi square and t tests were performed to test bivariate associations between provider type and survey measures.

RESULTS

Statistically significant differences (P < .05) between ONC and PCP perceptions were observed for several questions on communication between the 2 provider types, ONC perceptions of PCP ability to address survivorship care, and responsibilities for post-treatment care.

CONCLUSIONS

Highly discrepant perspectives between ONCs and PCPs regarding communications and responsibilities for survivorship care may lead to adverse health outcomes. Interventions aimed at improving care coordination for cancer survivors should define each provider group's responsibilities in survivorship care, and create structures and processes that foster clear channels of communication between ONC and PCP practices.

Exploring primary care level provider interpretation and management of potential breast and cervical cancer signs and symptoms in South Africa

Objectives

Women with potential breast and cervical cancer symptoms in South Africa (SA) usually self-present to primary health care (PHC) clinics. The aim of this study was to explore PHC provider interpretation and management of potential breast and cervical cancer signs and symptoms.

Methods

In-depth interviews with PHC providers incorporating vignettes were conducted between April and May 2019 in two sites in SA. Four vignettes (two breast and two cervical) were developed by the research team to capture aspects of provider symptom interpretation, reasoning, actions and challenges. The content of the vignettes was informed by a preceding community-based survey and qualitative interviews with symptomatic women. Interviews were audio recorded, transcribed verbatim and analysed using a thematic analysis approach.

Results

Twenty-four PHC providers were interviewed (12 urban, 12 rural; median age: 43 years). Four main themes relating to clinical assessment and reasoning; referral and feedback challenges; awareness of breast and cervical cancer policy guidelines and training and education needs emerged. Vignette-prompted questions relating to presenting symptoms, and possible accompanying symptoms and signs, demonstrated comprehensive proposed history taking and clinical assessment by PHC providers. Cancer was considered as a potential diagnosis by the majority of PHC providers. PHC providers also considered the possibility of infectious causes for both breast and cervical vignettes indicating they would ask questions around human immunodeficiency virus status, use of anti-retroviral therapy, and, for those with cervical symptoms, would need to rule out a sexually transmitted infection. Sexual assault was considered in assessing the cervical symptom scenarios. Providers raised issues around cumbersome booking systems and lack of feedback from referral centres. The need for provider and patient education and training to improve timely diagnosis of breast and cervical cancer was raised. Most providers were not aware of current breast or cervical cancer policy guidelines.

Conclusion

Clinical assessment at PHC level is complex and influenced by local health issues. Providing context-relevant training and support for PHC providers, and improving referral and feedback systems, could assist timely diagnosis of women with symptomatic breast and cervical cancer.

Assessment of Serum Selenium and Ceruloplasmin in Potentially Malignant Disorders and Oral Cancer

Introduction:

Despite extensive research and development, potentially malignant disorders (PMDs) of the oral cavity and oral cancer remain a serious concern. Diet and immunity have been identified as important modifiable factors in such diseases.

Materials and Methods:

A total of 20 patients and 10 healthy individuals, aged 30–60 years, were chosen from the outpatient Department of Oral and Maxillofacial Surgery, Yenepoya Dental College and hospital, Karnataka. The participants were grouped into three: Group 1: (10 healthy individuals), Group 2: (10 oral leukoplakia patients) and Group 3: (10 squamous cell carcinoma patients). Blood was chosen as the investigative medium. Ceruloplasmin was estimated by the diamine oxidase method. The technique of atomic absorption developed by Sir Alan Walsh in 1950 has become the preferred method of elemental analysis of selenium (atomic absorption spectrometer). Statistical analysis of the data obtained was done using one-way ANOVA test and the Turkey multiple comparisons test.

Results:

The intergroup comparison of ceruloplasmin shows that the mean value of Group I (Control) was 31.746 mg/dl, the mean value of Group II (leukoplakia) was 81.411 mg/dl, and the mean value of Group III (squamous cell carcinoma) was 90.7120 mg/dl. The intergroup comparison of selenium levels shows that the mean value of Group I (Control) was 119.937 (ng/ml), the mean value of Group II (leukoplakia) was 109.17 (ng/ml), and the mean value of Group III (squamous cell carcinoma) was 99.6230 (ng/ml).

Conclusion:

Antioxidants are an important defense system against free radical damage to cells. Ceruloplasmin and selenium levels in serum could be used as disease markers in leukoplakia and squamous cell carcinoma.

Implementing and Sustaining Early Cancer Diagnosis Initiatives in Canada: An Exploratory Qualitative Study

Background: The interval between suspected cancer and diagnosis for symptomatic patients is often fragmented, leading to diagnosis delays and increased patient stress. We conducted an exploratory qualitative study to explore barriers and facilitators to implementing and sustaining current initiatives across Canada that optimize early cancer diagnosis, with particular relevance for symptomatic patients. Methods: The national study included a document review and key informant interviews with purposefully recruited participants. Data were analyzed by two researchers using descriptive statistics and thematic analysis. Results: Twenty-two participants from eight provinces participated in key informant interviews and reported on 17 early cancer diagnosis initiatives. Most initiatives (88%) were in early phases of implementation. Two patient-facing and eight provider/organization barriers to implementation (e.g., lack of stakeholder buy-in and limited resources) and five facilitators for implementation and sustainability were identified. Opportunities to improve early cancer diagnosis initiatives included building relationships with stakeholders, co-creating initiatives, developing initiatives for Indigenous and underserved populations, optimizing efficiency and sustainability, and standardizing metrics to evaluate impact. Conclusion: Early cancer diagnosis initiatives in Canada are in early implementation phases. Lack of stakeholder buy-in and limited resources pose a challenge to sustainability. We present opportunities for funders and policymakers to optimize the use and potential impact of early cancer diagnosis initiatives.

Ten-year assessment of a cancer fast-track programme to connect primary care with oncology: reducing time from initial symptoms to diagnosis and treatment initiation

Background

Cancer is the second leading cause of mortality worldwide. Integrating different levels of care by implementing screening programmes, extending diagnostic tools and applying therapeutic advances may increase survival. We implemented a cancer fast-track programme (CFP) to shorten the time between suspected cancer symptoms, diagnosis and therapy initiation.

Patients and methods

Descriptive data were collected from the 10 years since the CFP was implemented (2009-2019) at the Clinico-Malvarrosa Health Department in Valencia, Spain. General practitioners (GPs), an oncology coordinator and 11 specialists designed guidelines for GP patient referral to the CFP, including criteria for breast, digestive, gynaecological, lung, urological, dermatological, head and neck, and soft tissue cancers. Patients with enlarged lymph nodes and constitutional symptoms were also considered. On identifying patients with suspected cancer, GPs sent a case proposal to the oncology coordinator. If criteria were met, an appointment was quickly made with the patient. We analysed the timeline of each stage of the process.

Results

A total of 4493 suspected cancer cases were submitted to the CFP, of whom 4019 were seen by the corresponding specialist. Cancer was confirmed in 1098 (27.3%) patients: breast cancer in 33%, urological cancers in 22%, gastrointestinal cancer in 19% and lung cancer in 15%. The median time from submission to cancer testing was 11 days, and diagnosis was reached in a median of 19 days. Treatment was started at a median of 34 days from diagnosis.

Conclusions

The findings of this study show that the interval from GP patient referral to specialist testing, cancer diagnosis and start of therapy can be reduced. Implementation of the CFP enabled most patients to begin curative intended treatment, and required only minimal resources in our setting.

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Our CFP easily connects GPs and hospital specialists.

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Our CFP shortens assessment time in patients with suspected cancer, adding to quality care.

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Our CFP decreases emotional stress in patients without cancer.

Epidemiology of Secondary Warm Autoimmune Haemolytic Anaemia-A Systematic Review and Meta-Analysis

Background: Warm autoimmune haemolytic anaemia (wAIHA) is a haemolytic disorder, most commonly seen among adults and is classified as either primary or secondary to an underlying disease. We describe the age and sex distribution and the proportion of secondary wAIHA. Method: We retrieved 2635 published articles, screened abstracts and titles, and identified 27 articles eligible for full-text review. From these studies, we extracted data regarding number of patients, sex distribution, age at diagnosis, number of patients with secondary wAIHA, and whether the patients were diagnosed through local or referral centres. All data were weighted according to the number of included patients in each study. Results: 27 studies including a total of 4311 patients with wAIHA, of which 66% were females, were included. The median age at diagnosis was 68.7 years, however, wAIHA affected all ages. The mean proportion of secondary wAIHA was 49%, most frequently secondary to systemic lupus erythematosus. The proportions of secondary wAIHA reported from primary vs. referral centres were 35% vs. 59%, respectively. Conclusion: This review consolidates previously reported gender distribution. The higher proportion of secondary wAIHA in referral centres suggests that the most severely affected patients are disproportionally more frequent in such facilities.

Are there opportunities to improve care as patients transition through the cancer care continuum? A scoping review protocol

INTRODUCTION

Transitions in Care (TiC) are vulnerable periods in care delivery associated with adverse events, increased cost and decreased patient satisfaction. Patients with cancer encounter many transitions during their care journey due to improved survival rates and the complexity of treatment. Collectively, improving TiC is particularly important among patients with cancer. The objective of this scoping review is to synthesise and map the existing literature regarding TiC among patients with cancer in order to explore opportunities to improve TiC among patients with cancer.

METHODS AND ANALYSIS

This scoping review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Scoping Review Extension and the Joanna Briggs Institute methodology. The PubMed cancer filter and underlying search strategy will be tailored to each database (Embase, Cochrane, CINAHL and PsycINFO) and combined with search terms for TiC. Grey literature and references of included studies will be searched. The search will include studies published from database inception until 9 February 2020. Quantitative and qualitative studies will be included if they describe transitions between any type of healthcare provider or institution among patients with cancer. Descriptive statistics will summarise study characteristics and quantitative data of included studies. Qualitative data will be synthesised using thematic analysis.

ETHICS AND DISSEMINATION

Our objective is to synthesise and map the existing evidence; therefore, ethical approval is not required. Evidence gaps around TiC will inform a programme of research aimed to improve high-risk transitions among patients with cancer. The findings of this scoping review will be published in a peer-reviewed journal and widely presented at academic conferences. More importantly, decision makers and patients will be provided a summary of the findings, along with data from a companion study, to prioritise TiC in need of interventions to improve continuity of care for patients with cancer.

Care coordination in two of Bogota’s public healthcare networks: A cross-sectional study among doctors

Introduction

Care coordination is a priority concern for healthcare systems. In Colombia, there is a lack of information on the topic. This study analysed how doctors of two Bogotá’s public healthcare networks perceived coordination between healthcare levels and what factors are associated with their perception.

Methods

A cross-sectional study using the COORDENA-CO questionnaire to a sample of 363 doctors (network-1 = 181; network-2 = 182) in 2015. The questionnaire asks about types and dimensions of care coordination: information and clinical management, with items in a Likert scale, as well as conditions regarding health system, organisational and doctors’ conditions. Descriptive statistics and logistic regression analysis were performed.

Results

The doctors’ perception of a high level of coordination did not exceed 25.4%. On coordination of information, limited transfer of clinical information was found. Concerning clinical management, there were limited care coherence, deficits in patient follow-up and lengthy waiting times for specialised care. A high perception of coordination were associated with being female, being over 50 years old, being a specialist, having less than one year’s working experience, working less than 20 h per week at the centre, forming part of network-1, having time available for performing coordination tasks, having job satisfaction and not identifying limitations imposed by healthcare insurers.

Discussion

There was limited perception of coordination, in its different dimensions and types with some differences between networks. The results support the importance of guaranteeing job satisfaction, ensuring sufficient time to coordination-related activities and intervening in the restrictions imposed by healthcare insurers to improve care coordination.

Understanding primary care-oncology relationships within a changing healthcare environment

Background

Management of care transitions from primary care into and out of oncology is critical for optimal care of cancer patients and cancer survivors. There is limited understanding of existing primary care-oncology relationships within the context of the changing health care environment.

Methods

Through a comparative case study of 14 innovative primary care practices throughout the United States (U.S.), we examined relationships between primary care and oncology settings to identify attributes contributing to strengthened relationships in diverse settings. Field researchers observed practices for 10–12 days, recording fieldnotes and conducting interviews. We created a reduced dataset of all text related to primary care-oncology relationships, and collaboratively identified patterns to characterize these relationships through an inductive “immersion/crystallization” analysis process.

Results

Nine of the 14 practices discussed having either formal or informal primary care-oncology relationships. Nearly all formal primary care-oncology relationships were embedded within healthcare systems. The majority of private, independent practices had more informal relationships between individual primary care physicians and specific oncologists. Practices with formal relationships noted health system infrastructure that facilitates transfer of patient information and timely referrals. Practices with informal relationships described shared commitment, trust, and rapport with specific oncologists. Regardless of relationship type, challenges reported by primary care settings included lack of clarity about roles and responsibilities during cancer treatment and beyond.

Conclusions

With the rapid transformation of U.S. healthcare towards system ownership of primary care practices, efforts are needed to integrate strengths of informal primary care-oncology relationships in addition to formal system driven relationships.

A Cancer Patient Journey: Complete Review During Acute Treatment Phase

Purpose: Cancer is a chronic illness with acute episodes lasting for years. Most cancer patients have coexisting comorbidities, which affect cancer treatment outcomes and make a shared care model for chronic diseases essential. There is a considerable gap between the achievable and delivered quality of care for cancer patients. Methods: We used a case study approach to examine the complexity of cancer management, from the perspective of one person's case as interpreted by the care team. It allowed the complexity of cancer management to retain its holistic and meaningful characteristics. We interviewed the patient, caregiver, primary care physician (PCP), and oncologist. Interviews were audio recorded and analyzed with ATLASti, qualitative statistical software. Participants also completed a basic demographic survey. Common themes were identified, analyzed, and discussed. Results: Main themes were lack of longitudinal relationship with PCP, communication barriers, and ambiguous health care provider roles. Communication barriers can be associated with the other two main themes. Conclusion: Our results showed that shared care for cancer management is lacking during the acute cancer treatment phase. Communication barriers between the PCP and oncologist along with lack of continuity of care and unclear role of the PCP are major contributors for fragmented cancer care in U.S. health care system.

Defining success factors to describe coordinated care in cancer

Providing coordinated care remains a challenge for cancer services globally. There is a lack of consensus in the literature about what constitutes successful coordinated care. This study aimed to define and prioritize a set of consensus-driven success factors that can lead to coordinated care. A mixed-methods approach was used that included literature review, a broad call for submissions from relevant stakeholders, and a priority-setting process based on a modified nominal group technique. Thirty articles that related to success factors in coordinated care were identified in the literature. Twenty submissions were received from a broad range of stakeholders. From these sources, a set of 20 success factors was derived. Seventy stakeholders attended a series of workshops across New South Wales, Australia, to review and prioritize these 20 success factors against significance and measurability. Clear consensus was reached on prioritizing two success factors linked to improving coordinated care from first presentation to diagnosis and ensuring that patients are routinely screened for physical and supportive care needs. Other highly ranked factors included the need for a comprehensive care plan and the identification of patients at higher risk for disjointed care. This study defines and prioritizes a set of success factors related to coordinated care in cancer. These success factors will be used to guide the development of interventions that target improving coordinated care as well as supporting the development of new funding models based on performance indicators derived from these factors.

How do the characteristics of breast cancer diagnostic assessment programmes influence service delivery: A mixed methods study

Diagnostic assessment programmes (DAPs) coordinate multidisciplinary teamwork (MDT), and improve wait times and patient satisfaction. No research has established optimal DAP design. This study explored how DAP characteristics influence service delivery. A mixed methods case study of four breast cancer DAPs was conducted including qualitative interviews with health-care providers and retrospective chart review. Data were integrated using multiple approaches. Twenty-three providers were interviewed; 411 medical records were reviewed. The number of visits and wait times from referral to diagnosis and consultation were lowest at a one-stop model. DAP characteristics (rural-remote region, human resources, referral volume, organisation of services, adherence to service delivery targets and one-stop model) may influence service delivery (number of visits, wait times). MDT, influenced by other DAP characteristics (co-location of staff, patient navigators, team functioning), may also influence service delivery. While the one-stop model may be ideal, all sites experienced similar and unique challenges. Further research is needed to understand how to optimise the organisation and delivery of DAP services. Measures reflecting individual, team and patient-reported outcomes should be used to assess the effectiveness and impact of DAPs in addition to more traditional measures such as wait times.

Chemotherapy treatment decision-making experiences of older adults with cancer, their family members, oncologists and family physicians: a mixed methods study

Purpose

Although comorbidities, frailty, and functional impairment are common in older adults (OA) with cancer, little is known about how these factors are considered during the treatment decision-making process by OAs, their families, and health care providers. Our aim was to better understand the treatment decision process from all these perspectives.

Methods

A mixed methods multi-perspective longitudinal study using semi-structured interviews and surveys with 29 OAs aged ≥70 years with advanced prostate, breast, colorectal, or lung cancer, 24 of their family members,13 oncologists, and 15 family physicians was conducted. The sample was stratified on age (70–79 and 80+). All interviews were analyzed using thematic analysis.

Results

There was no difference in the treatment decision-making experience based on age. Most OAs felt that they should have the final say in the treatment decision, but strongly valued their oncologists’ opinion. “Trust in my oncologist” and “chemotherapy as the last resort to prolong life” were the most important reasons to accept treatment. Families indicated a need to improve communication between them, the patient and the specialist, particularly around goals of treatment. Comorbidity and potential side-effects did not play a major role in the treatment decision-making for patients, families, or oncologists. Family physicians reported no involvement in decisions but desired to be more involved.

Conclusion

This first study using multiple perspectives showed neither frailty nor comorbidity played a role in the treatment decision-making process. Efforts to improve communication were identified as an opportunity that may enhance quality of care.

Condensed abstract

In a mixed methods study multiple perspective study with older adults with cancer, their family members, their oncologist and their family physician we explored the treatment decision making process and found that most older adults were satisfied with their decision. Comorbidity, functional status and frailty did not impact the older adult’s or their family members’ decision.

Electronic supplementary material

The online version of this article (doi:10.1007/s00520-016-3476-8) contains supplementary material, which is available to authorized users.

Oncologists' perceived barriers to an expanded role for primary care in breast cancer survivorship care

Concern exists about the sustainability of traditional, oncologist‐led models of breast cancer survivorship care. However, many oncologists are hesitant about deferring survivorship care to primary care providers (PCPs). Our objective was to examine oncologists' perceptions of the role PCPs play in breast cancer survivorship and the rationale underlying these perceptions. One‐on‐one interviews with medical, radiation, and surgical oncologists in Wisconsin were conducted (n = 35) and transcribed. Data analysis was performed using an inductive approach to content analysis. Oncologist‐perceived barriers included: PCP's level of experience with cancer care; Lack of PCP comfort in providing survivorship care; Existing demands on PCPs' time; Patient preference for oncology‐led survivorship care. Oncologists described familiarity and trust in individual PCPs as factors that could mitigate barriers and lead to increased PCP involvement in survivorship care. Although a number of perceived barriers to PCP participation in survivorship were identified by Wisconsin oncologists, our findings support the direction of ongoing initiatives to facilitate PCP involvement. Our findings also suggest that early PCP involvement in survivorship may increase PCP comfort and patients' trust in PCPs in this role. The identified barrier most challenging to address may be the limited capacity of the current primary care system to manage follow‐up for breast cancer survivors.

The Value of Continuity between Primary Care and Surgical Care in Colon Cancer

BACKGROUND

Improving continuity between primary care and cancer care is critical for improving cancer outcomes and curbing cancer costs. A dimension of continuity, we investigated how regularly patients receive their primary care and surgical care for colon cancer from the same hospital and whether this affects mortality and costs.

METHODS

Using Surveillance, Epidemiology, and End Results Program Registry (SEER)-Medicare data, we performed a retrospective cohort study of stage I-III colon cancer patients diagnosed between 2000 and 2009. There were 23,305 stage I-III colon cancer patients who received primary care in the year prior to diagnosis and underwent operative care for colon cancer. Patients were assigned to the hospital where they had their surgery and to their primary care provider's main hospital, and then classified according to whether these two hospitals were same or different. Outcomes examined were hazards for all-cause mortality, subhazard for colon cancer specific mortality, and generalized linear estimate for costs at 12 months, from propensity score matched models.

RESULTS

Fifty-two percent of stage I-III colon patients received primary care and surgical care from the same hospital. Primary care and surgical care from the same hospital was not associated with reduced all-cause or colon cancer specific mortality, but was associated with lower inpatient, outpatient, and total costs of care. Total cost difference was $8,836 (95% CI $2,746-$14,577), a 20% reduction in total median cost of care at 12 months.

CONCLUSIONS

Receiving primary care and surgical care at the same hospital, compared to different hospitals, was associated with lower costs but still similar survival among stage I-III colon cancer patients. Nonetheless, health care policy which encourages further integration between primary care and cancer care in order to improve outcomes and decrease costs will need to address the significant proportion of patients receiving health care across more than one hospital.

Electronic Trigger-Based Intervention to Reduce Delays in Diagnostic Evaluation for Cancer: A Cluster Randomized Controlled Trial

PURPOSE

We tested whether prospective use of electronic health record-based trigger algorithms to identify patients at risk of diagnostic delays could prevent delays in diagnostic evaluation for cancer.

METHODS

We performed a cluster randomized controlled trial of primary care providers (PCPs) at two sites to test whether triggers that prospectively identify patients with potential delays in diagnostic evaluation for lung, colorectal, or prostate cancer can reduce time to follow-up diagnostic evaluation. Intervention steps included queries of the electronic health record repository for patients with abnormal findings and lack of associated follow-up actions, manual review of triggered records, and communication of this information to PCPs via secure e-mail and, if needed, phone calls to ensure message receipt. We compared times to diagnostic evaluation and proportions of patients followed up between intervention and control cohorts based on final review at 7 months.

RESULTS

We recruited 72 PCPs (36 in the intervention group and 36 in the control group) and applied the trigger to all patients under their care from April 20, 2011, to July 19, 2012. Of 10,673 patients with abnormal findings, the trigger flagged 1,256 patients (11.8%) as high risk for delayed diagnostic evaluation. Times to diagnostic evaluation were significantly lower in intervention patients compared with control patients flagged by the colorectal trigger (median, 104 v 200 days, respectively; n = 557; P < .001) and prostate trigger (40% received evaluation at 144 v 192 days, respectively; n = 157; P < .001) but not the lung trigger (median, 65 v 93 days, respectively; n = 19; P = .59). More intervention patients than control patients received diagnostic evaluation by final review (73.4% v 52.2%, respectively; relative risk, 1.41; 95% CI, 1.25 to 1.58).

CONCLUSION

Electronic trigger-based interventions seem to be effective in reducing time to diagnostic evaluation of colorectal and prostate cancer as well as improving the proportion of patients who receive follow-up. Similar interventions could improve timeliness of diagnosis of other serious conditions.

A mixed-methods examination of communication between oncologists and primary care providers among primary care physicians in underserved communities

BACKGROUND

Research has demonstrated that communication and care coordination improve cancer patient outcomes. To improve communication and care coordination, it is important to understand primary care providers' (PCPs') perceptions of communication with oncologists as well as PCPs' communication needs.

METHODS

A mixed-methods approach was used in the present study. In the qualitative phase of the study, 18 PCPs practicing in underserved, minority communities were interviewed about their experiences communicating with oncologists. In the quantitative phase of the study, 128 PCPs completed an online survey about their preferences, experiences, and satisfaction with communication with oncologists.

RESULTS

Results indicated a PCP-oncologist gap in communication occurred between diagnosis and treatment. PCPs wanted more communication with oncologists, updates on their patients' prognosis throughout treatment, and to be contacted via telephone or email and saw their role as crucial in providing supportive care for their patients.

CONCLUSIONS

Although PCPs recognize that they play a critical, proactive role in supporting patients throughout the continuum of their cancer care experience, existing norms regarding postreferral engagement and oncologist-PCP communication often hinder activation of this role among PCPs. Expected standards regarding the method, frequency, and quality of postreferral communication should be jointly articulated and made accountable between PCPs and oncologists to help improve cancer patients' quality of care, particularly in minority communities.

Patient-centered, evidence-based, and cost-conscious cancer care across the continuum: Translating the Institute of Medicine report into clinical practice

In 2013, the Institute of Medicine (IOM) concluded that cancer care in the United States is in crisis. Patients and their families are not receiving the information that they need to make informed decisions about their cancer care. Many patients do not have access to palliative care and too few are referred to hospice at the appropriate point in their disease trajectory. Simultaneously, there is a growing demand for cancer care with increases in new cancer diagnoses and the number of patients surviving cancer. Furthermore, there is a workforce shortage to care for this growing and elderly population. The IOM's report, Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis, outlined recommendations to improve the quality of cancer care. This article provides an overview of the IOM report and highlights the recommendations that are most relevant to practicing clinicians who care for patients with cancer across the continuum. The implementation of the recommendations in clinical practice will require better patient-clinician communication, improved care coordination, targeted clinician training, effective dissemination of evidence-based guidelines and strategies for eliminating waste, and continuous quality assessment and improvement efforts.

Providing specialty consultant expertise to primary care: an expanding spectrum of modalities

In most models of health care delivery, the bulk of services are provided in primary care and there is frequent request for the input of specialty consultants. A critical issue for current and future health care systems is the effective and efficient delivery of specialist expertise for clinicians and patients. Input on a patient's care from specialty consultants usually requires a face-to-face visit between the patient and the consultant. New and complementary models of knowledge sharing have emerged. We describe a framework assessment of a spectrum of knowledge-sharing methods in the context of a patient-centered medical home. This framework is based on our experience in the Veterans Health Administration and a purposive review of the literature. These newer modes of specialty consultation include electronic consultation, secure text messaging, telemedicine of various types, and population preemptive consults. In addition to describing these modes of consultation, our framework points to several important areas in which further research is needed to optimize effectiveness.

Follow-up to abnormal cancer screening tests: considering the multilevel context of care

The call for multilevel interventions to improve the quality of follow-up to abnormal cancer screening has been out for a decade, but published work emphasizes individual approaches, and conceptualizations differ regarding the definition of levels. To investigate the scope and methods being undertaken in this focused area of follow-up to abnormal tests (breast, colon, cervical), we reviewed recent literature and grants (2007-2012) funded by the National Cancer Institute. A structured search yielded 16 grants with varying definitions of "follow-up" (e.g., completion of recommended tests, time to diagnosis); most included minority racial/ethnic group participants. Ten grants concentrated on measurement/intervention development and 13 piloted or tested interventions (categories not mutually exclusive). All studies considered patient-level factors and effects. Although some directed interventions at provider levels, few measured group characteristics and effects of interventions on the providers or levels other than the patient. Multilevel interventions are being proposed, but clarity about endpoints, definition of levels, and measures is needed. The differences in the conceptualization of levels and factors that affect practice need empirical exploration, and we need to measure their salient characteristics to advance our understanding of how context affects cancer care delivery in a changing practice and policy environment.

The colorectal cancer screening process in community settings: a conceptual model for the population-based research optimizing screening through personalized regimens consortium

Reducing colorectal cancer mortality by promoting screening has been a national goal for two decades. The NCI's Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium is the first federal initiative to foster coordinated, transdisciplinary research evaluating the entire cancer screening process in community settings. PROSPR is creating a central data repository to facilitate research evaluating the breast, cervical, and colorectal cancer screening process across different patient populations, provider types, and delivery systems. Data are being collected and organized at the multiple levels in which individuals are nested (e.g., healthcare systems, facilities, providers, and patients). Here, we describe a conceptual model of the colorectal cancer screening process guiding data collection and highlight critical research questions that will be addressed through pooled data. We also describe the three research centers focused on colorectal cancer screening with respect to study populations, practice settings, and screening policies. PROSPR comprehensively elucidates the complex screening process through observational study, and has potential to improve care delivery beyond the healthcare systems studied. Findings will inform intervention designs and policies to optimize colorectal cancer screening delivery and advance the Institute of Medicine's goals of effective, efficient, coordinated, timely, and safe health care with respect to evidence-based cancer screening.

Physician preferences and attitudes regarding different models of cancer survivorship care: a comparison of primary care providers and oncologists

PURPOSE

New strategies for delivering cancer follow-up care are needed. We surveyed primary care providers (PCPs) and oncologists to assess how physician attitudes toward and self-efficacy with cancer follow-up affect preferences for different cancer survivorship models.

METHODS

The survey of physician attitudes regarding the care of cancer survivors was mailed to a randomly selected national sample of PCPs and oncologists to evaluate their perspectives regarding physician roles, knowledge about survivorship care processes, and views on cancer surveillance. Multinomial logistic regression models were constructed to examine how physician attitudes towards, and self-efficacy with, their own skills affected preferences for different cancer survivorship care models.

RESULTS

Of 3,434 physicians identified, a total of 2,026 participants provided eligible responses: 938 PCPs and 1,088 oncologists. Most PCPs (51 %) supported a PCP/shared care model; whereas, the majority of specialists (59 %) strongly endorsed an oncologist-based model (p < 0.001). Less than a quarter of PCPs and oncologists preferred specialized survivor clinics. A significant proportion of oncologists (87 %) did not feel that PCPs should take on the primary role of cancer follow-up. Most PCPs believed that they were better able to perform breast and colorectal cancer follow-up (57 %), detect recurrent cancers (74 %), and offer psychosocial support (50 %), but only a minority (32 %) was willing to assume primary responsibility. PCPs already involved with cancer surveillance (43 %) were more likely to prefer a PCP/shared care than oncologist-based survivorship model (OR, 2.08; 95 % CI, 1.34-3.23).

CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS

PCPs and oncologists have different preferences for models of cancer survivorship care. Prior involvement with cancer surveillance was one of the strongest predictors of PCPs' willingness to assume this responsibility.

Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims

PURPOSE

To erform a process analysis of missed and delayed diagnoses of breast and colorectal cancers to identify: (1) the cognitive and logistical factors that lead to these diagnostic errors, and (2) prevention strategies.

METHODS

Using 56 cases (43 breast, 13 colon) of missed and delayed diagnosis, we performed structured analyses to identify specific points in the diagnostic process in which errors occurred. Each error was classified as either a cognitive error or logistical breakdown. Finally, two physician-investigators identified strategies to prevent the errors in each case.

RESULTS

Virtually all cases involved one or more cognitive errors (53/56, 95 %) and approximately half (31/56, 55 %) involved logistical breakdowns. The clinical activity most prone to cognitive error was the selection of the diagnostic strategy, both during the office visit (25/56, 45 %) and during interpretation of test results (22/50, 44 %). Arrangement of follow-up visits with a primary care physician (8/29, 28 %) or specialist physician (7/29, 26 %) were especially prone to logistical breakdowns. Adherence to current clinical guidelines could have prevented at least one error in 66 % of cases and assistance from a patient advocate could have prevented at least one error in 48 % of cases.

CONCLUSIONS

Cognitive errors and logistical breakdowns are common among missed and delayed diagnoses of breast and colorectal cancers. Prevention strategies should focus on ensuring improving the effectiveness and use of clinical guidelines in the selection of diagnostic strategy, both during office visits and when interpreting test results. Tools to facilitate communication and to ensure that follow-up visits occur should also be considered.

Reduced overall and event-free survival among colon cancer patients using dual system care

BACKGROUND

Many veterans have dual Veterans Administration (VA) and Medicare healthcare coverage. We compared 3-year overall and cancer event-free survival (EFS) among patients with nonmetastatic colon cancer who obtained substantial portions of their care in both systems and those whose care was obtained predominantly in the VA or in the Medicare fee-for-service system.

METHODS

We conducted a retrospective observational cohort study of patients older than 65 years with stages I to III colon cancer diagnosed from 1999 to 2001 in VA and non-VA facilities. Dual use of VA and non-VA colon cancer care was categorized as predominantly VA use, dual use, or predominantly non-VA use. Extended Cox regression models evaluated associations between survival and dual use.

RESULTS

VA and non-VA users (all stages) had reduced hazard of dying compared with dual users [e.g., for stage I, VA HR 0.40, 95% confidence interval (CI): 0.28-0.56; non-VA HR 0.54, 95% CI: 0.38-0.78). For EFS, stage I findings were similar (VA HR 0.47, 95% CI: 0.35-0.62; non-VA HR 0.64, 95% CI: 0.47-0.86). Stage II and III VA users, but not non-VA users, had improved EFS (stage II: VA HR 0.74, 95% CI: 0.56-0.97; non-VA HR 0.92, 95% CI: 0.69-1.22; stage III: VA HR 0.73, 95% CI: 0.56-0.94; non-VA HR 0.81, 95% CI: 0.62-1.06).

CONCLUSIONS

Improved survival among VA and non-VA compared with dual users raises questions about coordination of care and unmet needs.

IMPACT

Additional study is needed to understand why these differences exist, why patients use both systems, and how systems may be improved to yield better outcomes in this population.

A rationale for multidisciplinary care in treating neuroendocrine tumours

PURPOSE OF REVIEW

Disease heterogeneity and multisystem complications represent challenges to the diagnosis and management of neuroendocrine tumours (NET), with the disease often remaining undiagnosed for years after initial presentation. The purpose of this review is to assess the limitations of traditional care models and review the potential benefits of the multidisciplinary team approach in cancer treatment and to explore the potential usefulness of the multidisciplinary team approach for patients with NET.

RECENT FINDINGS

This article outlines important considerations for the multidisciplinary management of NET, offers a model for team structure and function and identifies skill sets of members that may augment patient care. We believe a multidisciplinary team should include three to four clinicians with extensive NET experience. A coordinating physician plays a crucial role by facilitating team cohesiveness and maintaining constant patient contact throughout the course of treatment. Our model emphasizes collaboration between members of the core team and can be extended to include interactions with community healthcare professionals and others.

SUMMARY

A multidisciplinary approach offers the best prospect for improving clinical outcomes and understanding the natural history of NET.

Under-diagnosis of pain by primary physicians and late referral to a palliative care team

Background

Under-diagnosis of pain is a serious problem in cancer care. Accurate pain assessment by physicians may form the basis of effective care. The aim of this study is to examine the association between late referral to a Palliative Care Team (PCT) after admission and the under-diagnosis of pain by primary physicians.

Methods

This retrospective study was performed in the Teikyo University teaching-hospital for a period of 20 months. We investigated triads composed of 213 adult cancer inpatients who had coexisting moderate or severe pain at the initial PCT consultation, 77 primary physicians, and 4 palliative care physicians. The outcome of the present study was the under-diagnosis of pain by primary physicians with routinely self-completed standard format checklists. The checklists included coexisting pain documented independently by primary and palliative care physicians at the time of the initial PCT consultation. Under-diagnosis of pain was defined as existing pain diagnosed by the palliative care physicians only. Late referral to PCTs after admission was defined as a referral to the PCT at ≥20 days after admission. Because the two groups displayed significantly different regarding the distributions of the duration from admission to referral to PCTs, we used 20 days as the cut-off point for “late referral.”

Results

Accurate pain assessment was observed in 192 triads, whereas 21 triads displayed under-diagnosis of pain by primary physicians. Under-diagnosis of pain by primary physicians was associated with a longer duration between admission and initial PCT consultation, compared with accurate pain assessment (25 days versus 4 days, p < 0.0001). After adjusting for potential confounding factors, under-diagnosis of pain by the primary physicians was significantly associated with late (20 or more days) referral to a PCT (adjusted odds ratio, 2.91; 95% confidence interval, 1.27 − 6.71). Other factors significantly associated with under-diagnosis of pain were coexisting delirium and case management by physicians with < 6 years of clinical experience.

Conclusions

Under-diagnosis of pain by primary physicians was associated with late referral to PCTs. Shortening the duration from admission to referral to PCTs, and increasing physicians’ awareness of palliative care may improve pain management for cancer patients.

Referrals for suspected hematologic malignancy: a survey of primary care physicians

Little is known about referrals from primary care providers (PCPs) for suspected hematologic malignancies, including their clinical triggers and frequency. A random sample of 190 Massachusetts PCPs were presented with a vignette concerning a patient with a new finding of moderate anemia, asked how they would respond, and then asked what they would do if the patient returned with persistent anemia plus one additional sign or symptom. We also asked about referral behaviors for suspected hematologic malignancies during the prior year. A total of 134 (70.5%) PCPs responded. At first anemia presentation,only 3.8% reported referring to hematology. The development of a second sign or symptom yielded higher referral rates: pancytopenia 588.7%, leukopenia 5 63.9%, thrombocytopenia 5 63.9%, lymphadenopathy 5 42.9%, leukocytosis 5 37.6%, night sweats 5 25.6%, and weight loss 5 23.3%. The median yearly number (interquartile range) of patients PCPs reported suspecting of having hematologic malignancy was 5 (3, 10), and the median formally referred was 5 (3, 10). We conclude that anemia plus signs and symptoms suggestive of myelodysplasia or leukemia (compared with those suggestive of lymphoma) are more likely to prompt hematology referral. In addition, given their rarity,the numbe

Introduction: Understanding and influencing multilevel factors across the cancer care continuum

Health care in the United States is notoriously expensive while often failing to deliver the care recommended in published guidelines. There is, therefore, a need to consider our approach to health-care delivery. Cancer care is a good example for consideration because it spans the continuum of health-care issues from primary prevention through long-term survival and end-of-life care. In this monograph, we emphasize that health-care delivery occurs in a multilevel system that includes organizations, teams, and individuals. To achieve health-care delivery consistent with the Institute of Medicine's six quality aims (safety, effectiveness, timeliness, efficiency, patient-centeredness, and equity), we must influence multiple levels of that multilevel system. The notion that multiple levels of contextual influence affect behaviors through interdependent interactions is a well-established ecological view. This view has been used to analyze health-care delivery and health disparities. However, experience considering multilevel interventions in health care is much less robust. This monograph includes 13 chapters relevant to expanding the foundation of research for multilevel interventions in health-care delivery. Subjects include clinical cases of multilevel thinking in health-care delivery, the state of knowledge regarding multilevel interventions, study design and measurement considerations, methods for combining interventions, time as a consideration in the evaluation of effects, measurement of effects, simulations, application of multilevel thinking to health-care systems and disparities, and implementation of the Affordable Care Act of 2010. Our goal is to outline an agenda to proceed with multilevel intervention research, not because it guarantees improvement in our current approach to health care, but because ignoring the complexity of the multilevel environment in which care occurs has not achieved the desired improvements in care quality outlined by the Institute of Medicine at the turn of the millennium.

Differences between primary care physicians' and oncologists' knowledge, attitudes and practices regarding the care of cancer survivors

BACKGROUND

The growing number of cancer survivors combined with a looming shortage of oncology specialists will require greater coordination of post-treatment care responsibilities between oncologists and primary care physicians (PCPs). However, data are limited regarding these physicians' views of cancer survivors' care.

OBJECTIVE

To compare PCPs and oncologists with regard to their knowledge, attitudes, and practices for follow-up care of breast and colon cancer survivors.

DESIGN AND SUBJECTS

Mailed questionnaires were completed by a nationally representative sample of 1,072 PCPs and 1,130 medical oncologists in 2009 (cooperation rate = 65%). Sampling and non-response weights were used to calculate estimates to reflect practicing US PCPs and oncologists.

MAIN MEASURES

PCPs and oncologists reported their 1) preferred model for delivering cancer survivors' care; 2) assessment of PCPs' ability to perform follow-up care tasks; 3) confidence in their knowledge; and 4) cancer surveillance practices.

KEY RESULTS

Compared with PCPs, oncologists were less likely to believe PCPs had the skills to conduct appropriate testing for breast cancer recurrence (59% vs. 23%, P < 0.001) or to care for late effects of breast cancer (75% vs. 38%, P < 0.001). Only 40% of PCPs were very confident of their own knowledge of testing for recurrence. PCPs were more likely than oncologists to endorse routine use of non-recommended blood and imaging tests for detecting cancer recurrence, with both groups departing substantially from guideline recommendations.

CONCLUSION

There are significant differences in PCPs' and oncologists' knowledge, attitudes, and practices with respect to care of cancer survivors. Improving cancer survivors' care may require more effective communication between these two groups to increase PCPs' confidence in their knowledge, and must also address oncologists' attitudes regarding PCPs' ability to care for cancer survivors.

Outside the box: will information technology be a viable intervention to improve the quality of cancer care?

The use of health information technology (IT) to resolve the crisis in communication inherent within the fragmented service environment of medical care in the United States is a strategic priority for the Department of Health and Human Services. Yet the deployment of health IT alone is not sufficient to improve quality in health service delivery; what is needed is a human factors approach designed to optimize the balance between health-care users, health-care providers, policies, procedures, and technologies. An evaluation of interface issues between primary and specialist care related to cancer reveals opportunities for human factors improvement along the cancer care continuum. Applications that emphasize cognitive support for prevention recommendations and that encourage patient engagement can help create a coordinated health-care environment conducive to cancer prevention and early detection. An emphasis on reliability, transparency, and accountability can help improve the coordination of activities among multiple service providers during diagnosis and treatment. A switch in emphasis from a transaction-based approach to one emphasizing long-term support for healing relationships should help improve patient outcomes during cancer survivorship and end-of-life care. Across the entire continuum of care, an emphasis on "meaningful use" of health IT-rather than on IT as an endpoint-should help put cancer on a path toward substantive continuous quality improvement. The accompanying research questions will focus on reducing the variance between the social and technical subsystems as IT is used to improve patient outcomes across the interfaces of care.

Factors in quality care--the case of follow-up to abnormal cancer screening tests--problems in the steps and interfaces of care

To achieve the benefit of cancer screening, appropriate follow-up of abnormal screening test results must occur. Such follow-up requires traversing the transition between screening detection and diagnosis, including several steps and interfaces in care. This article reviews factors and interventions associated with follow-up of abnormal tests for cervical, breast and colorectal cancers. We synthesized 12 reviews of descriptive and intervention studies published between 1980 and 2008. There was wide variability in definition of follow-up, setting, study population, and reported prevalence rates. Correlates of follow-up included patient characteristics (eg, knowledge and age), social support, provider characteristics, practice (eg, having reminders systems), community and professional norms (eg, quality measures), and policy (eg, federal programs). Effective interventions included patient education and support; delivery systems design changes, such as navigation; and information system changes, most notably patient tracking and physician reminders. Few studies focused explicitly on interfaces and steps of care, such as communication between primary care and specialists, or simultaneously targeted the multilevel factors that affect care. Future practice and research priorities should include development of clear operational definitions of the steps and interfaces related to patients, providers, and organizations; reflect evolving guidelines and new technologies; determine priorities for intervention testing; and improve measures and apply appropriate study designs.