The two solitudes of primary care and cancer specialist care: is there a bridge?

Using care pathways for cancer diagnosis in primary care: a qualitative study to understand family physicians' mental models

BACKGROUND

Care pathways are tools that can help family physicians navigate the complexities of the cancer diagnostic process. Our objective was to examine the mental models associated with using care pathways for cancer diagnosis of a group of family physicians in Alberta.

METHODS

We conducted a qualitative study using cognitive task analysis, with interviews in the primary care setting between February and March 2021. Family physicians whose practices were not heavily oriented toward patients with cancer and who did not work closely with specialized cancer clinics were recruited with the support of the Alberta Medical Association and leveraging our familiarity with Alberta's Primary Care Networks. We conducted simulation exercise interviews with 3 pathway examples over Zoom, and we analyzed data using both macrocognition theory and thematic analysis.

RESULTS

Eight family physicians participated. Macrocognitive functions (and subthemes) related to mental models were sense-making and learning (confirmation and validation, guidance and support, and sense-giving to patients), care coordination and diagnostic decision-making (shared understanding). Themes related to the use of the pathways were limited use in diagnosis decisions, use in guiding and supporting referral, only relevant and easy-to-process information, and easily accessible.

INTERPRETATION

Our findings suggest the importance of designing pathways intentionally for streamlined integration into family physicians' practices, highlighting the need for co-design approaches. Pathways were identified as a tool that, used in combination with other tools, may help gather information and support cancer diagnosis decisions, with the goals of improving patient outcomes and care experience.

Factors Associated with the Breast Cancer Diagnostic Interval across Five Canadian Provinces: A CanIMPACT Retrospective Cohort Study

The cancer diagnostic process can be protracted, and it is a time of great anxiety for patients. The objective of this study was to examine inter- and intra-provincial variation in diagnostic intervals and explore factors related to the variation. This was a multi-province retrospective cohort study using linked administrative health databases. All females with a diagnosis of histologically confirmed invasive breast cancer in British Columbia (2007-2010), Manitoba (2007-2011), Ontario (2007-2010), Nova Scotia (2007-2012), and Alberta (2004-2010) were included. The start of the diagnostic interval was determined using algorithms specific to whether the patient's cancer was detected through screening. We used multivariable quantile regression analyses to assess the association between demographic, clinical and healthcare utilization factors with the diagnostic interval outcome. We found significant inter- and intra-provincial variation in the breast cancer diagnostic interval and by screen-detection status; patients who presented symptomatically had longer intervals than screen-detected patients. Interprovincial diagnostic interval variation was 17 and 16 days for screen- and symptom-detected patients, respectively, at the median, and 14 and 41 days, respectively, at the 90th percentile. There was an association of longer diagnostic intervals with increasing comorbid disease in all provinces in non-screen-detected patients but not screen-detected. Longer intervals were observed across most provinces in screen-detected patients living in rural areas. Having a regular primary care provider was not associated with a shorter diagnostic interval. Our results highlight important findings regarding the length of the breast cancer diagnostic interval, its variation within and across provinces, and its association with comorbid disease and rurality. We conclude that diagnostic processes can be context specific, and more attention should be paid to developing tailored processes so that equitable access to a timely diagnosis can be achieved.

Physician perspectives on delays in cancer diagnosis in Alberta: a qualitative study

BACKGROUND

Delays in cancer diagnosis have been associated with reduced survival, decreased quality of life after treatment, and suboptimal patient experience. The objective of the study was to explore the perspectives of a group of family physicians and other specialists regarding potentially avoidable delays in diagnosing cancer, and approaches that may help expedite the process.

METHODS

We conducted a qualitative study using interviews with physicians practising in primary and outpatient care settings in Alberta between July and September 2019. We recruited family physicians and specialists who were in a position to discuss delays in cancer diagnosis by email via the Cancer Strategic Clinical Network and the Alberta Medical Association. We conducted semistructured interviews over the phone, and analyzed data using thematic analysis.

RESULTS

Eleven family physicians and 22 other specialists (including 7 surgeons or surgical oncologists, 3 pathologists, 3 radiologists, 2 emergency physicians and 2 hematologists) participated in interviews; 22 were male (66.7%). We identified 4 main themes describing 9 factors contributing to potentially avoidable delays in diagnosis, namely the nature of primary care, initial presentation, investigation, and specialist advice and referral. We also identified 1 theme describing 3 suggestions for improvement, including system integration, standardized care pathways and a centralized advice, triage and referral support service for family physicians.

INTERPRETATION

These findings suggest the need for enhanced support for family physicians, and better integration of primary and specialty care before cancer diagnosis. A multifaceted and coordinated approach to streamlining cancer diagnosis is required, with the goals of enhancing patient outcomes, reducing physician frustration and optimizing efficiency.

Cross-sectoral communication by bringing together patient with cancer, general practitioner and oncologist in a video-based consultation: a qualitative study of oncologists' and nurse specialists' perspectives

Shared care models in the field of cancer aim to improve care coordination, role clarification and patient satisfaction. Cross-sectoral communication is pivotal. Involvement of patients may add to intended mechanisms.A randomised controlled trial 'The Partnership Study' tested the effect of bringing together patient, general practitioner (GP) and oncologist for a consultation conducted by video.

PURPOSE

As part of the process evaluation, this study aimed to explore experiences, attitudes and perspectives of the oncological department on sharing patient consultations with GPs using video.

METHODS

Four semistructured interviews with five oncologists and four nurse specialists were conducted in February 2020. We focused on the informants' experiences and reflections on the potential of future implementation of the concept 'inviting the GP for a shared consultation by video'. The analyses were based on an inductive, open-minded, hermeneutic phenomenological approach.

RESULTS

A total of six overall themes were identified: structuring consultation and communication, perceptions of GP involvement in cancer care, stressors, making a difference, alternative ways of cross-sector communication and needs for redesigning the model. The concept made sense and was deemed useful, but solving the many technical and organisational problems is pivotal. Case-specific tasks and relational issues were targeted by pragmatically rethinking protocol expectations and the usual way of communication and structuring patient encounters. Case selection was discussed as one way of maturing the concept.

CONCLUSION

This Danish study adds new insight into understanding different aspects of the process, causal mechanisms as well as the potential of future implementation of video-based tripartite encounters. Beyond solving the technical problems, case selection and organisational issues are important. Acknowledging the disruption of the usual workflow, the introduction of new phases of the usual encounter and the variety of patient-GP relationships to be embraced may help to better understand and comply with barriers and facilitators of communication and sharing.

TRIAL REGISTRATION NUMBER

NCT02716168.

Contextual factors influencing the implementation of innovations in community-based primary health care: the experience of 12 Canadian research teams

The objectives of this paper are to: (1) identify contextual factors such as policy that impacted the implementation of community-based primary health care (CBPHC) innovations among 12 Canadian research teams and (2) describe strategies used by the teams to address contextual factors influencing implementation of CBPHC innovations. In primary care settings, consideration of contextual factors when implementing change has been recognized as critically important to success. However, contextual factors are rarely recorded, analyzed or considered when implementing change. The lack of consideration of contextual factors has negative implications not only for successfully implementing primary health care (PHC) innovations, but also for their sustainability and scalability. For this evaluation, data collection was conducted using self-administered questionnaires and follow-up telephone interviews with team representatives. We used a combination of directed and conventional content analysis approaches to analyze the questionnaire and interview data. Representatives from all 12 teams completed the questionnaire and 11 teams participated in the interviews; 40 individuals participated in this evaluation. Four themes representing contextual factors that impacted the implementation of CBPHC innovations were identified: (I) diversity of jurisdictions (II) complexity of interactions and collaborations (III) policy, and (IV) the multifaceted nature of PHC. The teams used six strategies to address these contextual factors including: (1) conduct an environmental scan at the beginning (2) maintaining engagement among partners and stakeholders by encouraging open and inclusive communication; (3) contextualizing the innovation for different settings; (4) anticipating and addressing changes, delays, and the need for additional resources; (5) fostering a culture of research and innovation among partners and stakeholders; and (6) ensuring information about the innovation is widely available. Implementing CBPHC innovations across jurisdictions is complex and involves navigating through multiple contextual factors. Awareness of the dynamic nature of context should be considered when implementing innovations.

Comparing enrolees with non-enrolees of cancer-patient navigation at end of life

Background

Cancer-patient navigators who are oncology nurses support and connect patients to resources throughout the cancer care trajectory, including end of life. Although qualitative and cohort studies of navigated patients have been reported, no population-based studies were found. The present population-based study compared demographic, disease, and outcome characteristics for decedents who had been diagnosed with cancer by whether they did or did not see a navigator.

Methods

This retrospective study used patient-based administrative data in Nova Scotia (cancer registry, death certificates, navigation visits) to generate descriptive statistics. The study population included all adults diagnosed with cancer who died during 2011-2014 of a cancer or non-cancer cause of death.

Results

Of the 7694 study decedents, 74.9% had died of cancer. Of those individuals, 40% had seen a navigator at some point in their disease trajectory. The comparable percentage for those who did not die of cancer was 11.9%. Decedents at the oldest ages had the lowest navigation rates. Navigation rates, time from diagnosis to death, and time from last navigation visit to death varied by disease site.

Conclusions

This population-based study of cancer-patient navigation enrolees compared with non-enrolees is the first of its kind. Most findings were consistent with expectations. However, we do not know whether the rates of navigation are consistent with the navigation needs of the population diagnosed with cancer. Because more people are living longer with cancer and because the population is aging, ongoing surveillance of who requires and who is using navigation services is warranted.