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Bulls HW, Hamm M, Wasilewski J, Olejniczak D, Bell SG, Liebschutz JM. "To prescribe or not to prescribe, that is the question": Perspectives on opioid prescribing for chronic, cancer-related pain from clinicians who treat pain in survivorship. Cancer 2024; 130:3034-3042. [PMID: 38567685 DOI: 10.1002/cncr.35299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/03/2024] [Accepted: 03/05/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Opioid pain management in cancer survivorship is a complex and understudied topic. METHODS The authors conducted in-depth, qualitative interviews to understand clinician approaches to opioid pain management in chronic cancer pain and to generate ideas for improvement. They used a rigorous, inductive, qualitative, descriptive approach to examine clinician (n = 20) perspectives about opioid pain management in survivorship, including oncologists (n = 5), palliative care clinicians (n = 8), primary care clinicians (n = 5), and pain management specialists (n = 2). RESULTS The findings indicated that no consistent medical home exists for chronic pain management in cancer survivors and that there are fundamental differences in how each subspecialty approaches chronic pain management in survivorship (e.g., "Do we think of this as noncancer pain or cancer pain?… This is in this limbo zone-this gray zone-because it's cancer-related pain, right?"). Simultaneously, clinicians are influenced by their peers' perceptions of their opioid prescribing decisions, sparking intraprofessional tension when disagreement occurs. In these instances, clinicians described overthinking and doubting their clinical decision-making as well as a sense of judgment, pressure, and/or shame. Finally, clinicians acknowledged a fear of consequences for opioid prescribing decisions. Specifically, participants cited conflict with patients, sometimes escalating to aggression and threats of violence, as well as potential disciplinary actions and/or legal consequences. CONCLUSIONS Participants suggested that opportunities to improve chronic cancer pain care include developing clear, systematic guidance for chronic cancer pain management, facilitating clinician communication and consultation, creating tailored survivorship care plans in partnership with patients, and developing accessible, evidence-based, complementary pain treatments.
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Affiliation(s)
- Hailey W Bulls
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Challenges in Managing and Preventing Pain Clinical Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Megan Hamm
- Qualitative, Evaluation, and Stakeholder Engagement Services, Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Julia Wasilewski
- Qualitative, Evaluation, and Stakeholder Engagement Services, Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Donna Olejniczak
- Division of General Internal Medicine, Department of Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sarah G Bell
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jane M Liebschutz
- Division of General Internal Medicine, Department of Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Dowrick A, Ziebland S, Rai T, Friedemann Smith C, Nicholson BD. A manifesto for improving cancer detection: four key considerations when implementing innovations across the interface of primary and secondary care. Lancet Oncol 2024; 25:e388-e395. [PMID: 38848741 DOI: 10.1016/s1470-2045(24)00102-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/09/2024] [Accepted: 02/15/2024] [Indexed: 06/09/2024]
Abstract
Improving cancer outcomes through innovative cancer detection initiatives in primary care is an international policy priority. There are unique implementation challenges to the roll-out and scale-up of different innovations, requiring synchronisation between national policy levers and local implementation strategies. We draw on implementation science to highlight key considerations when seeking to sustainably embed cancer detection initiatives within health systems and clinical practice. Points of action include considering the implications of change on the current configuration of responsibility for detecting cancer; investing in understanding how to adapt systems to support innovations; developing strategies to address inequity when planning innovation implementation; and anticipating and making efforts to mitigate the unintended consequences of innovation. We draw on examples of contemporary cancer detection issues to illustrate how to apply these recommendations to practice.
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Affiliation(s)
- Anna Dowrick
- Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK.
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Tanvi Rai
- Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | | | - Brian D Nicholson
- Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
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Stout NL, Boatman D, Rice M, Branham E, Miller M, Salyer R. Unmet Needs and Care Delivery Gaps Among Rural Cancer Survivors. J Patient Exp 2024; 11:23743735241239865. [PMID: 38505492 PMCID: PMC10949551 DOI: 10.1177/23743735241239865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024] Open
Abstract
Community-based healthcare delivery systems frequently lack cancer-specific survivorship support services. This leads to a burden of unmet needs that is magnified in rural areas. Using sequential mixed methods we assessed unmet needs among rural cancer survivors diagnosed between 2015 and 2021. The Supportive Care Needs Survey (SCNS) assessed 5 domains; Physical and Daily Living, Psychological, Support and Supportive Services, Sexual, and Health Information. Needs were analyzed across domains by cancer type. Survey respondents were recruited for qualitative interviews to identify care gaps. Three hundred and sixty two surveys were analyzed. Participants were 85% White (n = 349) 65% (n = 234) female and averaged 2.03 years beyond cancer diagnosis. Nearly half (49.5%) of respondents reported unmet needs, predominantly in physical, psychological, and health information domains. Needs differed by stage of disease. Eleven interviews identified care gap themes regarding; Finding Support and Supportive Services and Health Information regarding Care Delivery and Continuity of Care. Patients experience persistent unmet needs after a cancer diagnosis across multiple functional domains. Access to community-based support services and health information is lacking. Community based resources are needed to improve access to care for long-term cancer survivors.
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Affiliation(s)
- Nicole L Stout
- Department of Cancer Prevention and Control, School of Medicine, West Virginia University, Morgantown, WV, USA
- Department of Health Policy, Management, and Leadership, School of Public, West Virginia University, Morgantown, WV, USA
| | - Dannell Boatman
- Department of Cancer Prevention and Control, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Madeline Rice
- Division of Physical Therapy, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Emelia Branham
- Division of Physical Therapy, School of Medicine, West Virginia University, Morgantown, WV, USA
| | | | - Rachel Salyer
- Department of Internal Medicine, School of Medicine, West Virginia University, Morgantown, WV, USA
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Moscovice IS, Parsons H, Bean N, Santana X, Weis K, Hui JYC, Lahr M. Availability of cancer care services and the organization of care delivery at critical access hospitals. Cancer Med 2023; 12:17322-17330. [PMID: 37439021 PMCID: PMC10501243 DOI: 10.1002/cam4.6337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/15/2023] [Accepted: 07/02/2023] [Indexed: 07/14/2023] Open
Abstract
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.
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Affiliation(s)
- Ira S. Moscovice
- Flex Monitoring Team, Division of Health Policy and ManagementUniversity of Minnesota School of Public HealthMinneapolisMinnesotaUSA
| | - Helen Parsons
- Division of Health Policy and ManagementUniversity of Minnesota School of Public HealthMinneapolisMinnesotaUSA
| | - Nathan Bean
- Hennepin County Department of Public HealthMinneapolisMinnesotaUSA
| | - Xiomara Santana
- Flex Monitoring Team, Division of Health Policy and ManagementUniversity of Minnesota School of Public HealthMinneapolisMinnesotaUSA
| | - Kate Weis
- University of Minnesota Medical SchoolMinneapolisMinnesotaUSA
| | - Jane Yuet Ching Hui
- Division of Surgical Oncology, Department of SurgeryUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Megan Lahr
- Flex Monitoring Team, Division of Health Policy and ManagementUniversity of Minnesota School of Public HealthMinneapolisMinnesotaUSA
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Stockman LS, Gundersen DA, Gikandi A, Akindele RN, Svoboda L, Pohl S, Drews MR, Lathan CS. The Colocation Model in Community Cancer Care: A Description of Patient Clinical and Demographic Attributes and Referral Pathways. JCO Oncol Pract 2023:OP2200487. [PMID: 36940391 DOI: 10.1200/op.22.00487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023] Open
Abstract
PURPOSE Cancer disparities are well documented among Black, Indigenous, and People of Color, yet little is known about the characteristics of programs that serve these populations. Integrating specialized cancer care services within community settings is important for addressing the needs of historically marginalized populations. Our National Cancer Institute-Designated Cancer Center initiated a clinical outreach program incorporating cancer diagnostic services and patient navigation within a Federally Qualified Health Center (FQHC) to expedite evaluation and resolution of potential cancer diagnoses with the goal of collaboration between oncology specialists and primary care providers in a historically marginalized community in Boston, MA. MATERIALS AND METHODS Sociodemographic and clinical characteristics were analyzed from patients who were referred to the program for cancer-related care between January 2012 and July 2018. RESULTS The majority of patients self-identified as Black (non-Hispanic) followed by Hispanic (Black and White). Twenty-two percent of patients had a cancer diagnosis. Treatment and surveillance plans were established for those with and without cancer at a median time to diagnostic resolution of 12 and 28 days, respectively. The majority of patients presented with comorbid health conditions. There was a high prevalence of self-reported financial distress among patients seeking care through this program. CONCLUSION These findings highlight the wide spectrum of cancer care concerns in historically marginalized communities. This review of the program suggests that integrating cancer evaluation services within community-based primary health care settings offers promise for enhancing the coordination and delivery of cancer diagnostic services among historically marginalized populations and could be a method to address clinical access disparities.
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Affiliation(s)
- Leah S Stockman
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Daniel A Gundersen
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ajami Gikandi
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ruth N Akindele
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ludmila Svoboda
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Sarah Pohl
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Christopher S Lathan
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
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Granroth G, Khera N, Arana Yi C. Progress and Challenges in Survivorship After Acute Myeloid Leukemia in Adults. Curr Hematol Malig Rep 2022; 17:243-253. [PMID: 36117228 PMCID: PMC9483315 DOI: 10.1007/s11899-022-00680-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Acute myeloid leukemia (AML) survivors face unique challenges affecting long-term outcomes and quality of life. There is scant literature on the long-term impact of AML treatment in physical and mental health, disease recurrence, and financial burden in survivors. RECENT FINDINGS Fatigue, mental health concerns, infections, sexual dysfunction, and increase cancer recurrence occur after AML treatment. Chronic graft-versus-host disease (GVHD) and infections are common concerns in AML after hematopoietic stem cell transplantation (HCT). Survivorship guidelines encompass symptoms and complications but fail to provide an individualized care plan for AML survivors. Studies in patient-reported outcomes (PROs) and health-related quality of life (HRQoL) are sparse. Here we discuss the most common aspects pertaining to AML survivorship, late complications, care delivery, prevention of disease recurrence, and potential areas for implementation.
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Seidel K, Quasdorf T, Haberstroh J, Thyrian JR. Adapting a Dementia Care Management Intervention for Regional Implementation: A Theory-Based Participatory Barrier Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:5478. [PMID: 35564877 PMCID: PMC9101206 DOI: 10.3390/ijerph19095478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 11/16/2022]
Abstract
Dementia is a leading cause of disability and dependency in older people worldwide. As the number of people affected increases, so does the need for innovative care models. Dementia care management (DCM) is an empirically validated approach for improving the care and quality of life for people with dementia (PwD) and caregivers. The aim of this study is to investigate the influencing factors and critical pathways for the implementation of a regionally adapted DCM standard in the existing primary care structures in the German region of Siegen-Wittgenstein (SW). Utilizing participatory research methods, five local health care experts as co-researchers conducted N = 13 semi-structured interviews with 22 local professionals and one caregiver as peer reviewers. Data collection and analysis were based on the Consolidated Framework for Implementation Research (CFIR). Our results show that among the most mentioned influencing factors, three CFIR constructs can be identified as both barriers and facilitators: Patients' needs and resources, Relative advantage, and Cosmopolitanism. The insufficient involvement of relevant stakeholders is the major barrier and the comprehensive consideration of patient needs through dementia care managers is the strongest facilitating factor. The study underlines the vital role of barrier analysis in site-specific DCM implementation.
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Affiliation(s)
- Katja Seidel
- Psychological Ageing Research, Department of Psychology, Faculty V: School of Life Sciences, University of Siegen, Adolf-Reichwein-Str. 2a, 57068 Siegen, Germany;
| | - Tina Quasdorf
- German Center for Neurodegenerative Diseases (DZNE), Site Witten, Stockumer Str. 12, 58453 Witten, Germany;
- Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58455 Witten, Germany
| | - Julia Haberstroh
- Psychological Ageing Research, Department of Psychology, Faculty V: School of Life Sciences, University of Siegen, Adolf-Reichwein-Str. 2a, 57068 Siegen, Germany;
| | - Jochen René Thyrian
- German Center for Neurodegenerative Diseases (DZNE), Site Rostock/Greifswald, Ellernholzstr. 1/2, 17489 Greifswald, Germany;
- Institute for Community Medicine, University Medicine Greifswald, Ellernholzstr. 1-2, 17489 Greifswald, Germany
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