The Impact of COVID-19 on the All of Us Research Program

The All of Us Research Program, a health and genetics epidemiologic data collection program, has been substantially affected by the coronavirus disease 2019 (COVID-19) pandemic. Although the program is highly digital in nature, certain aspects of the data collection require in-person interaction between staff and participants. Before the pandemic, the program was enrolling approximately 12,500 participants per month at more than 400 clinical sites. In March 2020, because of the pandemic, all in-person activity at program sites and by engagement partners was paused to develop processes and procedures for in-person activities that incorporated strict safety protocols. In addition, the program adopted new data collection methodologies to reduce the need for in-person activities. Through February 2022, a total of 224 clinical sites had reactivated in-person activity, and all enrollment and engagement partners have adopted new data collection methods that can be used remotely. As the COVID-19 pandemic persists, the program continues to require safety procedures for in-person activity and continues to generate and pilot methodologies that reduce risk and make it easier for participants to provide information.

Oncologist-Reported Reasons for Not Ordering Multimarker Tumor Panels: Results From a Nationally Representative Survey

This study examines oncologist-reported reasons for not using multimarker tumor panel testing and the association between these reasons and oncologist-level, facility-level, and patient-mix characteristics.

METHODS

We used data collected from a nationally representative sample (N = 1,281) of medical oncologists participating in the National Cancer Institute's National Survey of Precision Medicine in Cancer Treatment.

RESULTS

In addition to testing not being seen as relevant (87%) and no evidence of test utility (77%), the most frequently reported reasons for not ordering a multimarker tumor panel test was difficulty in obtaining sufficient tissue (57%) and using individual gene tests (72%). These reasons were more likely to be reported by oncologists practicing in rural clinics and less likely to be reported by oncologists with an academic affiliation or with access to genetic services such as on-site genetic counselors and internal genetic testing policies.

CONCLUSION

Modifiable, organizational factors were associated with ordering multimarker tumor panels. Receipt of genomics training and organizational policies related to the use of genomics were associated with lower reporting of barriers to ordering multimarker tumor panels, pointing to potential targets for future studies aimed at increasing appropriate multimarker tumor panel testing in cancer treatment management.

Involving patients and their families in deciding to use next generation sequencing: Results from a nationally representative survey of U.S. oncologists

OBJECTIVE

Next generation sequencing (NGS) may aid in tumor classification and treatment. Barriers to shared decision-making may influence use of NGS. We examined, from oncologists' perspectives, whether barriers to involving patients/families in decision-making were associated with NGS use.

METHODS

Using data from the first national survey of medical oncologists' perspectives on precision medicine (N = 1281), we approached our analyses in two phases. Bivariate analyses initially evaluated associations between barriers to involving patients/families in deciding to use NGS and provider- and organizational-level characteristics. Modified Poisson regressions then examined associations between patient/family barriers and NGS use.

RESULTS

Approximately 59 % of oncologists reported at least one barrier to involving patients/families in decision-making regarding NGS use. Those reporting patient/family barriers tended to have fewer genomic resources at their practices, to be in rural or suburban areas, and to have a higher proportion of Medicaid patients. However, these barriers were not associated with NGS use.

CONCLUSIONS

Oncologists encounter barriers to involving patients/families in NGS testing decisions. Organizational barriers may also potentially play a role in testing decisions.

PRACTICE IMPLICATIONS

To foster patient-centered care, strategies to support patient involvement in genomic testing decisions are needed, particularly among practices in low-resource settings.

The National Cancer Institute Community Cancer Centers Program (NCCCP): Sustaining Quality and Reducing Disparities in Guideline-Concordant Breast and Colon Cancer Care

This study builds on analyses performed as part of an original comprehensive National Cancer Institute Community Cancer Centers Program evaluation and examines improvements in quality of care. The following research questions are addressed: (a) have improvements in concordance rates with the five quality of care measures been sustained since 2010 and (b) how does the change in concordance for minority/underserved patients compare to the change for nonminority/nonunderserved patients through 2013?

Background.

The National Cancer Institute Community Cancer Centers Program (NCCCP) pilot was designed to improve quality of cancer care and reduce disparities at community hospitals. The NCCCP's primary intervention was the implementation of the Commission on Cancer Rapid Quality Reporting System (RQRS). The RQRS is a hospital‐based data collection and evaluation system allowing near real‐time assessment of selected breast and colon cancer quality of care measures. Building on previous NCCCP analyses, this study examined whether improvements in quality cancer care within NCCCP hospitals early in the program were sustained and whether improvements were notable for minority or underserved populations.

Methods.

We compared changes in concordance with three breast and two colon cancer quality measures approved by the National Quality Forum for patients diagnosed at NCCCP hospitals from 2006 to 2007 (pre‐RQRS), 2008 to 2010 (early‐RQRS), and 2011 to 2013 (later‐RQRS). Data were obtained from NCCCP sites participating in the Commission on Cancer Rapid Quality Reporting System. Logistic regression analyses were performed to identify predictors of concordance with breast and colon cancer quality measures.

Results.

The sample included 13,893 breast and 5,546 colon cancer patients. After RQRS initiation, all five quality measures improved significantly and improvements were sustained through 2013. Quality of care measures showed sustained improvements for both breast and colon cancer patients and for vulnerable patient subgroups including black, uninsured, and Medicaid‐covered patients.

Conclusions.

Quality improvements in NCCCP hospitals were sustained throughout the duration of the program, both overall and among minority and underserved patients. Because many individuals receive cancer treatment at community hospitals, facilitating high‐quality care in these environments must be a priority.

Implications for Practice.

Quality improvement programs often improve practice, but the methods are not maintained over time. The implementation of a real‐time quality reporting system and a network focused on improving quality of care sustained quality improvement at select community cancer centers. The NCCCP pilot increased numbers of patients receiving guideline‐concordant care for breast and colon cancer in community settings, and initial improvements noted in earlier years of RQRS were sustained into later years, both overall and among minority and underserved patients. National initiatives that improve care for diverse patient groups are important for reducing and eliminating barriers to care.

NCI Community Cancer Center Program (NCCCP): Understanding why hormonal therapy for breast cancer was considered but not administered

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Background: The National Cancer Institute Community Cancer Centers Program (NCCCP) was designed to improve the quality of cancer care and reduce disparities at hospital-based community cancer centers. This study examined when guideline-concordant therapy was considered but not administered, who made the decision to not receive treatment. Methods: A retrospective analysis of patients diagnosed and receiving all or part of their initial cancer treatment at one of 12 NCCCP sites was conducted. We examined patients who were guideline-concordant with the hormonal therapy (HT) for breast cancer quality measure, but for whom treatment was considered but not administered. We compared patients diagnosed in the pre-NCCCP period (2006 – 2007) and during the NCCCP period (2008-2013). Results: Overall, a low proportion of cases had HT considered but not administered (4% in pre-NCCCP period; 5% in NCCCP period – difference not significant). In the pre-NCCCP period, white patients were twice as likely as Black patients to have HT considered but not administered, while there were no racial differences during the NCCCP period. In both time periods, older patients and Medicare patients were more likely to have HT considered but not administered. The most common reason for considering but not administering HT was refusal by the patient or patient’s family and this more likely for White patients, patients in the middle age groups (50-59 and 60 to 69), and Medicare patients. The second most common reason was that the physician determined it to be contraindicated due to patient risk factors. This was more likely to be a reason for Black and Medicaid patients. Conclusions: Results show that a large proportion of cases that had treatment considered but not administered did not receive treatment because of patient/family refusal or it was contraindicated due to other patient risk factors, both before and during the NCCCP period. Additional studies could inform the long-term outcomes of patients with comorbid conditions who were considered for guideline-concordant treatment but did not receive it (but the data were not available for this study).

NCI Community Cancer Center Program (NCCCP): Disparities in time between cancer diagnosis and treatment initiation

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Background: The National Cancer Institute Community Cancer Centers Program (NCCCP) was designed to improve care and reduce cancer disparities at community hospitals. This study examined the number of days between diagnosis and treatment for five National Quality Forum-endorsed cancer quality measures. Methods: A retrospective analysis of data from patients diagnosed and receiving breast or colon cancer treatment at 12 NCCCP sites was performed. We examined time to treatment for cancer quality measures, stratified by concordant and non-concordant patients. We compared patients diagnosed before (2006 – 2007) vs. during (2008-2013) the NCCCP period. Results: Concordant Cases. Time to treatment was significantly greater in the NCCCP vs. pre-NCCCP periods for three measures. Compared to pre-the NCCCP period, time to treatment in the NCCCP period was longer by 26 days for women with breast cancer receiving hormonal therapy (HT). Time to HT increased significantly among most patient and hospital subgroups (race, age, insurance, hospital size). Black, Medicaid, and/or uninsured patients generally had longer-than-average time to treatment for all measures when receiving guideline-concordant care. Non-Concordant Cases. Among women with breast cancer who received treatment outside the measure window, most eligible for multi-agent chemotherapy received treatment within one month after the cut-off. In contrast, a majority eligible for other cancer quality measures received treatment more than one after the cut-off. Among women who were non-concordant for HT, those with Medicare or private insurance were significantly more likely to begin HT within one month after the cut-off than were those with Medicaid. Conclusions: More than half of patients non-concordant on cancer quality measures received treatment more than one month after the treatment window. However, many were non-concordant because they were just outside the time window to be considered concordant (< 30 days), particularly Medicaid patients. Rapid reporting of quality indicators could inform targeted efforts to improve care coordination and concordance rates, particularly among certain patient subgroups.

ReCAP: Impact of Multidisciplinary Care on Processes of Cancer Care: A Multi-Institutional Study

PURPOSE

The role of multidisciplinary care (MDC) on cancer care processes is not fully understood. We investigated the impact of MDC on the processes of care at cancer centers within the National Cancer Institute Community Cancer Centers Program (NCCCP).

METHODS

The study used data from patients diagnosed with stage IIB to III rectal cancer, stage III colon cancer, and stage III non–small-cell lung cancer at 14 NCCCP cancer centers from 2007 to 2012. We used an MDC development assessment tool—with levels ranging from evolving MDC (low) to achieving excellence (high)—to measure the level of MDC implementation in seven MDC areas, such as case planning and physician engagement. Descriptive statistics and cluster-adjusted regression models quantified the association between MDC implementation and processes of care, including time from diagnosis to treatment receipt.

RESULTS

A total of 1,079 patients were examined. Compared with patients with colon cancer treated at cancer centers reporting low MDC scores, time to treatment receipt was shorter for patients with colon cancer treated at cancer centers reporting high or moderate MDC scores for physician engagement (hazard ratio [HR] for high physician engagement, 2.66; 95% CI, 1.70 to 4.17; HR for moderate physician engagement, 1.50; 95% CI, 1.19 to 1.89) and longer for patients with colon cancer treated at cancer centers reporting high 2MDC scores for case planning (HR, 0.65; 95% CI, 0.49 to 0.85). Results for patients with rectal cancer were qualitatively similar, and there was no statistically significant difference among patients with lung cancer.

CONCLUSION

MDC implementation level was associated with processes of care, and direction of association varied across MDC assessment areas.

Assessing the Development of Multidisciplinary Care: Experience of the National Cancer Institute Community Cancer Centers Program

PURPOSE

The National Cancer Institute Community Cancer Centers Program (NCCCP) began in 2007 with a goal of expanding cancer research and delivering quality care in communities. The NCCCP Quality of Care (QoC) Subcommittee was charged with developing and improving the quality of multidisciplinary care. An assessment tool with nine key elements relevant to MDC structure and operations was developed.

METHODS

Fourteen NCCCP sites reported multidisciplinary care assessments for lung, breast, and colorectal cancer in June 2010, June 2011, and June 2012 using an online reporting tool. Each site evaluated their level of maturity (level 1 = no multidisciplinary care, level 5 = highly integrated multidisciplinary care) in nine elements integral to multidisciplinary care. Thematic analysis of open-ended qualitative responses was also conducted.

RESULTS

The proportion of sites that reported level 3 or greater on the assessment tool was tabulated at each time point. For all tumor types, sites that reached this level increased in six elements: case planning, clinical trials, integration of care coordination, physician engagement, quality improvement, and treatment team integration. Factors that enabled improvement included increasing organizational support, ensuring appropriate physician participation, increasing patient navigation, increasing participation in national quality initiatives, targeting genetics referrals, engaging primary care providers, and integrating clinical trial staff.

CONCLUSIONS

Maturation of multidisciplinary care reflected focused work of the NCCCP QoC Subcommittee. Working group efforts in patient navigation, genetics, and physician conditions of participation were evident in improved multidisciplinary care performance for three common malignancies. This work provides a blueprint for health systems that wish to incorporate prospective multidisciplinary care into their cancer programs.

NCI Community Cancer Centers Program (NCCCP): Percent improvement in guideline-concordant breast and colon cancer care for disparate patient populations

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Background: The NCI Community Cancer Center Program (NCCCP) pilot launched in 2007 to improve quality and reduce disparities in patients receiving care in community hospital-based cancer centers. This study assessed the percent improvement in guideline-concordant cancer care since NCCCP initiation, overall and for disparate patient populations. Methods: We conducted a retrospective analysis of patients diagnosed and receiving treatment at one of 12 NCCCP sites. We compared percent improvement in concordance for NQF-approved quality measures: 3 breast (BCS-radiation following breast conserving surgery; HT-hormonal therapy; and MAC-multi-agent chemotherapy) and 2 colon (12RLN-12 regional lymph nodes examined during surgery; and ACT-adjuvant chemotherapy). Sample included patients diagnosed 2006 to 2007 (baseline, or pre-NCCCP) and 2008 to 2013 (NCCCP). Percent improvement was defined as the difference in concordance between baseline and NCCCP periods divided by baseline concordance. Results: Between baseline and NCCCP periods, improvement was noted for all 5 measures. The HT concordance rate improved by 55.1% (from 58.2% to 90.3%). For all breast measures, Black patients showed significantly larger than average percent improvement (p<.05). For BCS and ACT, Medicaid and uninsured patients showed significantly larger than average percent improvement (p<.05). Larger than average improvement was also noted in hospitals in high-poverty markets and in markets with few physicians. Conclusions: The percent of patients receiving guideline concordant breast or colon cancer care increased significantly since Program initiation, particularly among certain disparate patient subgroups. Future analyses will examine issues of disparities in timeliness of treatment.Funded by NCI Contract HHSN261200800001E. [Table: see text]

Expectations of discipline representation on multidisciplinary treatment planning (MTP) teams

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Background: The Commission on Cancer’s (CoC) standards require accredited cancer programs to utilize a multidisciplinary team approach for treatment planning. A recent CoC survey sought to characterize current multidisciplinary treatment planning (MTP) practice from the cancer programs’ perspective. Methods: The survey, administered to 1,261 programs, included items on team structure and process, case presentation, clinical trials and patient involvement. Each facility was designated to report on MTP for one cancer type: Breast, Gastrointestinal (GI), Lung, Head/Neck, Gynecologic (Gyn), Brain/Central Nervous System (CNS). A total of 797 (63%) facilities responded. Initial analyses highlight the disciplines expected to attend MTP meetings. Results: Forty-eight percent expected all core physician specialties (Medical Oncology, Radiation Oncology, Surgery and/or Surgical Oncology), to attend the initial case presentation. Respondents also expected affiliated specialists and professionals to attend initial case presentations, and included pathologists (90%), clinical trials nurses (46%), patient navigators (37%), primary care providers (20%), and genetic counselors (18%). Data analysis demonstrated significant variation in expected disciplinary attendance for select providers depending on type of cancer program, as illustrated below (Table). Analysis by cancer type showed that primary care physicians were expected to attend Lung MTP meetings at 25% of the facilities compared to Breast (15%). Genetic counselors were expected to attend MTP meetings for Breast (29%), Gyn (24%), and GI (18%). Additional analyses are ongoing. Conclusions: To improve cancer care quality, the CoC has put forward standards to foster multidisciplinary professional participation in the treatment of cancer care. Findings indicate expectations of attendance for key disciplines at MTP meetings vary by tumor–specific MTP and by type of cancer program. Key genetic markers for certain sites may also explain why genetic counselors are expected to attend. [Table: see text]

Improving quality of care within the NCI Community Cancer Centers Program (NCCCP) network

178

Background: The National Cancer Institute (NCI) Community Cancer Centers Program (NCCCP) was initiated to expand cancer research and deliver quality cancer care in communities. A program goal was support of quality care initiatives. Twenty-one community sites in 16 states participated in the network providing care to approximately 40,000 cancer patients/year. We describe strategies for implementation of a structured quality program within our network. Methods: Four components served as the foundation for quality efforts: 1) increasing multidisciplinary care (MDC) programs; 2) ASCO QOPI participation; 3) Commission on Cancer Rapid Quality Reporting System (RQRS) participation; and 4) expansion of genetic counseling/services. A Quality of Care subcommittee formed to guide quality efforts within the network. Clinicians from the network served as subcommittee leadership and each site designated a quality of care lead. The subcommittee met by teleconference monthly, developed goals, shared best practices, developed processes to accomplish goals and documented improvements in priority areas. Results: Strategies employed to improve quality included: assessment tool development, participation in national quality reporting initiatives, review and monitoring of network data, and network performance improvement projects. Conclusions: The NCCCP identified areas of needed quality improvement. In addition, the network developed implementation strategies and created benchmarks that measure program quality. Participants benefitted from the opportunity to interface with one another and set network goals, while adopting strategies to best fit their own practices and community sites. [Table: see text]

Patient involvement in multidisciplinary treatment planning (MTP)

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Background: Patient involvement in treatment decision-making has been well-studied. However, little is known about how patients are involved in the MTP process prior to their consideration of treatment options. Methods: An online survey was administered to 1,261 Commission on Cancer (CoC)-accredited programs to describe current MTP practice. Survey items addressed team structure and process, case presentation, and patient involvement. A total of 797 (63%) facilities responded. Multiple aspects of patient involvement focusing on the initial case presentation and post-meeting follow-up regarding information provision and communication are examined. Initial descriptive analyses are presented. Results: 97% of facilities reported patients are not invited to attend MTP meetings. Reasons for not inviting patients included: patients may find it overwhelming (62%), physicians not able to speak freely (58%), liability (43%) and privacy (42%) concerns. Of the facilities that do invite patients, 1/3 reported that patients often or always attend. Treatment recommendations from MTP meetings are shared with patients at 75% of facilities, 42% share treatment plans, and 28% give a meeting summary to patients. Nine percent of facilities do not give patients any information from the meeting. Prior to treatment, a written treatment plan is developed at 43% of facilities, and among these, 15% give the plan to patients. Regarding communication about MTP meetings, facilities reported pre-meeting discussions with attending physicians (95%) and patient navigators (21%). Post-meeting follow-up by 93% of facilities is usually done by physicians, 26% by patient navigators and 16% by PA/NPs, and 66% follow-up within 1 week. Conclusions: Initial findings suggest that even if facilities do not invite patients to MTP meetings, they engage patients in various ways at pre- and post-MTP meetings, providing information and having discussions. Physicians are integral in communicating with patients throughout the MTP process. Further study on the multiple facets of patient involvement in MTP is needed to better understand its influence on treatment decision-making.

Improving quality of cancer care at community hospitals: impact of the National Cancer Institute Community Cancer Centers Program pilot

PURPOSE

Patients with cancer treated at community hospitals may experience decreased quality of care compared with patients treated at higher-volume cancer hospitals. The National Cancer Institute Community Cancer Centers Program (NCCCP) pilot is designed to enhance research and improve cancer care at community hospitals. We assessed changes in quality of care among the 16 initial NCCCP sites versus 25 similar hospitals that did not participate in the NCCCP.

METHODS

We compared changes in concordance with five National Quality Forum-approved quality of care measures (three for breast cancer, two for colon cancer) for patients diagnosed from 2006 to 2007 (pre-NCCCP initiation) versus 2008 to 2010 (post-NCCCP initiation) at NCCCP and comparison-group hospitals. Data were collected using the Commission on Cancer Rapid Quality Reporting System. Analyses were performed using multivariate logistic regression.

RESULTS

Analyses included 18,608 patients with breast cancer and 7,031 patients with colon cancer. After NCCCP initiation, patient-level concordance rates for all five quality-of-care measures increased significantly among NCCCP and comparison-group hospitals. Increased quality of care among NCCCP sites was significantly greater than that among comparison-group hospitals for radiation therapy after breast-conserving surgery and hormonal therapy for women with hormone receptor-positive breast cancer. In multivariate regressions, increases in hormonal therapy among NCCCP-site patients were significantly greater than those among comparison-group hospitals.

CONCLUSION

Both NCCCP and comparison-group hospitals showed improved quality of care; however, NCCCP sites had significantly greater improvements for a subset of measures. This greater increase may reflect the multidisciplinary focus of the NCCCP. Because many individuals receive cancer treatment at community hospitals, facilitating high-quality care in these environments must be a priority.

Evolution of multidisciplinary care: Experience of the National Cancer Institute (NCI) Community Cancer Centers Program (NCCCP)

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Background: A key aim of the NCCCP is to develop and improve the quality of multidisciplinary care (MDC). An assessment tool with nine key elements relevant to MDC structure and operations was developed to assess MDC maturity and set goals for continued quality improvement at individual sites and across the network. Methods: 14 NCCCP sites self-reported MDC assessments for lung, breast, and colorectal cancer in June 2010, 2011, and 2012 using an online reporting tool. Each site evaluated their level of maturity (level 1 = no MDC, level 5 = highly integrated MDC) in nine elements integral to the MDC process. Qualitative review of sites’ responses was also conducted. Results: MDC improvement was most evident in four of nine elements; case planning (CP), physician engagement (PE), integration of care coordination (ICC), and quality improvement (QI). The number of sites at level 3 or greater is reported in the table below. Integration of primary care providers and increased organizational support contributed to improved CP. PE was related to conditions of participation, insuring involvement of appropriate physicians in the MDC. The network focus on patient navigation was demonstrated by increase of ICC. Improvement in QI was related to increased participation of sites in physician and hospital quality initiatives (i.e., QOPI and RQRS), and an NCCCP project aimed at increasing referrals to genetics for patient with breast and colon cancer. Conclusions: The maturity of MDC reflected focused work of the Quality of Care sub-committee of the NCCCP. The efforts of working groups in patient navigation, genetics and physician conditions of participation was made evident in the improved performance in MDC’s for three of the four most common malignancies seen in the United States. We hope that this work will provide a blueprint for other health systems that wish to incorporate multidisciplinary care into their cancer programs. [Table: see text]

Time issues in multilevel interventions for cancer treatment and prevention

The concept of time introduces important complexities in estimating intervention effects, program and evaluation design, and measurement and analysis of individual change in multilevel interventions (MLIs). Despite growing recognition that time is a critical element for assessing both individual-level outcomes and higher-level changes in organizational, community, and policy contexts, most MLI designs and evaluations have not addressed these issues. In this chapter we discuss 1) conceptualizing disease life-course and treatment theory in MLIs, 2) approaches to incorporating time in research and program design for MLIs in cancer treatment and prevention, 3) analysis of time-varying multilevel data in the context of cancer treatment and prevention, and 4) resource considerations and trade-offs of incorporating time as a dimension of MLIs and analysis. Although analytic techniques for analyzing time-related phenomena are becoming more available and powerful, there has not been corresponding progress made in the development of theory to guide the application of these techniques in program design and implementation.

Association of increases in quality of care with the NCI Community Cancer Center Program (NCCCP) pilot

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Background: The NCCCP pilot is an initiative designed to enhance research and improve cancer care at community hospitals. As part of a multi-method evaluation of this pilot, we assessed changes in quality of care among the 16 pilot NCCCP hospitals over time (before vs. after program initiation) and in comparison to a group of 25 similar hospitals that did not participate in the NCCCP. Methods: We compared changes in 5 NQF-approved quality of care measures (3 for breast cancer, 2 for colon cancer) from 2006/07 (before NCCCP initiation) vs. 2008/09/10 (post-initiation) for NCCCP and comparison group hospitals. Data were collected from all study hospitals using the Commission on Cancer’s Rapid Quality Reporting System, which allowed near real-time tracking of quality of care process measures. Results: Analyses included 18,608 breast cancer and 7,031 colon cancer patients. Patient-level concordance rates for all 5 quality of care measures increased significantly among both NCCCP and comparison group hospitals. The change (from baseline to post-NCCCP) in quality of care among NCCCP hospitals was significantly greater than the change among comparison group hospitals for two measures: radiation therapy following breast conserving surgery (RT-BCS) and hormonal therapy for women with hormone receptor positive breast cancer (HT). For the RT-BCS measure, NCCCP patients from underserved populations also experienced significantly greater changes in concordance than did corresponding populations from comparison group hospitals. In multivariate regression analyses controlling for patient characteristics, the change for the HT measure among NCCCP hospitals was significantly greater than that among comparison group hospitals. Conclusions: While both NCCCP and comparison group hospitals showed improved quality of care, participation in the NCCCP was associated with significantly greater improvements for a subset of measures. Including a separate comparison hospital group was critical for assessing changes associated with NCCCP participation while controlling for broader U.S. trends in improved quality of care. Future work will examine how hospital networks may have facilitated improvements in quality of care.

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.

Multilevel interventions and racial/ethnic health disparities

To examine the impact of multilevel interventions (with three or more levels of influence) designed to reduce health disparities, we conducted a systematic review and meta-analysis of interventions for ethnic/racial minorities (all except non-Hispanic whites) that were published between January 2000 and July 2011. The primary aims were to synthesize the findings of studies evaluating multilevel interventions (three or more levels of influence) targeted at ethnic and racial minorities to reduce disparities in their health care and obtain a quantitative estimate of the effect of multilevel interventions on health outcomes among these subgroups. The electronic database PubMed was searched using Medical Subject Heading terms and key words. After initial review of abstracts, 26 published studies were systematically reviewed by at least two independent coders. Those with sufficient data (n = 12) were assessed by meta-analysis and examined for quality using a modified nine-item Physiotherapy Evidence Database coding scheme. The findings from this descriptive review suggest that multilevel interventions have positive effects on several health behavior outcomes, including cancer prevention and screening, as well improving the quality of health-care system processes. The weighted average effect size across studies for all health behavior outcomes reported at the individual participant level (k = 17) was odds ratio (OR) = 1.27 (95% confidence interval [CI] = 1.11 to 1.44); for the outcomes reported by providers or organizations, the weighted average effect size (k = 3) was OR = 2.53 (95% CI = 0.82 to 7.81). Enhanced application of theories to multiple levels of change, novel design approaches, and use of cultural leveraging in intervention design and implementation are proposed for this nascent field.

The organization of multidisciplinary care teams: modeling internal and external influences on cancer care quality

Quality cancer treatment depends upon careful coordination between multiple treatments and treatment providers, the exchange of technical information, and regular communication between all providers and physician disciplines involved in treatment. This article will examine a particular type of organizational structure purported to regularize and streamline the communication between multiple specialists and support services involved in cancer treatment: the multidisciplinary treatment care (MDC) team. We present a targeted review of what is known about various types of MDC team structures and their impact on the quality of treatment care, and we outline a conceptual model of the connections between team context, structure, process, and performance and their subsequent effects on cancer treatment care processes and patient outcomes. Finally, we will discuss future research directions to understand how MDC teams improve patient outcomes and how characteristics of team structure, culture, leadership, and context (organizational setting and local environment) contribute to optimal multidisciplinary cancer care.

The partnership for cancer prevention: addressing access to cervical cancer screening among Latinas in South Carolina

BACKGROUND

Cancer is a leading cause of morbidity and morality among Hispanics, the fastest growing population group in South Carolina (SC). The Partnership for Cancer Prevention (PCP) was established to build partnerships and community capacity to address cervical cancer early detection and control among the growing Latina population in SC. In this paper we report on the initial PCP community-based participatory research (CBPR) project.

METHODS

PCP members engaged in a multi-method, participatory research project to assess cervical cancer related resources and needs among Latinas and healthcare providers. To explore attitudes and behaviors related to women's health in general and more specifically, female cancer, PCP members conducted 8 focus group sessions with 38 Spanish-speaking women. To assess the availability and perceived importance of culturally and linguistically appropriate services, PCP members conducted a survey of providers (n=46) and support personnel (n=30) at 14 clinical sites that provide cancer screening services.

RESULTS

Health care access issues were Latinas' main concerns. For information and assistance in accessing and navigating the health care system, they relied on informal social networks and community outreach workers. Latina participants voiced misunderstandings about cancer risk and most appeared to lack a prevention orientation. Practitioners’ concerns included the assessment and documentation of patients' language preference and ability, provision of language assistance for limited-English-proficient (LEP) patients, and bilingual staff.

CONCLUSIONS

Building on the findings of this participatory research initiative, PCP members identified the following action strategies to promote cervical cancer screening among Latinas in SC: culturally appropriate cervical cancer awareness messages and outreach strategies geared towards increasing participation in cervical cancer screening and follow-up; maintenance of active community partnerships for health promotion, cancer risk reduction, and improved access to care; and increasing the capacity of the health care systems in SC to address Hispanic health concerns.

Breast cancer survival among economically disadvantaged women: the influences of delayed diagnosis and treatment on mortality

Breast cancer affects thousands each year in the United States, and disproportionately affects certain subgroups. For example, the incidence of breast cancer in South Carolina is lower in African American compared with European American women by approximately 12% to 15%, but their mortality rate is twice as high as in European American women. The purpose of the study was to assess factors associated with breast cancer mortality between African American and European American women. Participants (n=314) in South Carolina's Breast and Cervical Cancer Early Detection Program (SCBCCEDP), which provides breast cancer screening and treatment services, during the years 1996-2004 were included in the study. Data, including tumor characteristics, delay intervals, and race, were examined using the chi(2) test and the Wilcoxon rank-sum test. Cox regression modeling was used to assess the relationship between delay intervals and other factors. No racial differences were found in age at diagnosis, tumor characteristics, or delay intervals. Time delay intervals did not explain differences and mortality rates by race. Survival, however, was affected by prognostic factors as well as by a significant interaction between hormone-receptor status and race. Despite the excellent record of the SCBCCEDP in screening and diagnostic or treatment referrals, the racial disparities in breast cancer mortality continue to exist in South Carolina. These findings highlight the need for future research into the etiology of racial differences, and their impact on breast cancer survival.

Understanding Barriers for Adherence to Follow-Up Care for Abnormal Pap Tests

OBJECTIVE

Approximately 4000 women annually will die from preventable and treatable cervical cancer. Failure to adhere to follow-up recommendations after an abnormal Pap test can lead to development of cervical cancer. This paper summarizes the body of literature on adherence to follow-up after an abnormal Pap test in order to facilitate development of interventions to decrease morbidity and mortality due to cervical cancer.

METHODS

We conducted a comprehensive search of published literature addressing risk factors for adherence or interventions to improve adherence following an abnormal Pap test as the outcome. We included peer-reviewed original research conducted in the United States from 1990 to 2005.

RESULTS

Fourteen analytical and twelve experimental studies that met our criteria were reviewed. Lesion severity and health beliefs were consistently associated with adherence rates. Communication interventions, including telephone reminders, counseling, and educational sessions, increased follow-up compliance across intervention studies. Inconsistent evidence for associations among race, income, and age were found.

CONCLUSIONS

Further research is needed to reinforce current studies addressing health beliefs and social support. Interventions that focus on the interplay among psychological, educational, and communication barriers are necessary. These interventions should be adapted and applied across various racial/ethnic and socioeconomic groups to reach all women with a high-risk profile for invasive cervical cancer.

What predicts adherence to follow-up recommendations for abnormal Pap tests among older women?

OBJECTIVE

To address socio-demographic factors associated with adherence to follow-up recommendations in a high-risk population of women referred for follow-up care after an abnormal Pap test.

METHODS

486 women aged 46-64 served by BCCEDP in two southeastern states between 1999-2002 and referred for follow-up care after an abnormal Pap test were the sampling frame for this cross-sectional study; 204 women completed a phone-based interview in 2004. Cox proportional hazards modeling was used to determine the association of various risk factors with time to adherence.

RESULTS

Among those completing the phone interview (interview rate=61.4%) the mean age was 53.3 years, 64.7% were African-American women, 81.9% had low-grade cervical lesions, and all were either uninsured or under insured. Over 95% received follow-up care for an abnormal Pap test within 365 days of referral. When the BCCEDP criteria of follow-up within 60 days were applied, 52.9% were adherent. Rates of self-reported and program documented adherence differed significantly by state. After adjusting for state of residence, women who reported having symptoms of a chronic disease were more likely to be adherent within 365 days (aHR=1.42; 95% CI=1.00, 2.04). Neither age, race, lesion severity, education, number of dependent adults or children, self-perceived physical health, nor smoking status was associated with time to adherence.

CONCLUSIONS

Findings suggest that institutional factors may be more important than individual factors in predicting time to adherence for an abnormal Pap test.

Tailored risk notification for women with a family history of breast cancer

BACKGROUND

Evidence indicates that although first-degree relatives of breast cancer cases are at increased risk of developing the disease themselves, they may be underutilizing screening mammography. Therefore, interventions to increase the use of mammography in this group are urgently needed.

METHODS

A randomized two-group design was used to evaluate an intervention to increase mammography use among women (N = 901) with at least one first-degree relative with breast cancer. A statewide cancer registry was used to obtain a random sample of breast cancer cases who identified eligible relatives. The mailed intervention consisted of personalized risk notification and other theoretically driven materials tailored for high-risk women.

RESULTS

An overall significant intervention effect was observed (8% intervention group advantage) in mammography at post-test. There was an interaction of the intervention with age such that there was no effect among women <50 years of age and a fairly large (20% advantage) effect among women 50+ and 65+. Health insurance, education, and having had a mammogram in the year before baseline assessment were positive predictors of mammography at post-test. Perceived risk, calculated risk, and relationship to index cancer case were not associated with mammography receipt.

CONCLUSION

The intervention was successful in increasing mammography rates among high-risk women 50+ years of age. Further work is needed to determine why it was ineffective among younger women.

Evaluation of an intervention to increase mammography screening in Los Angeles

METHODS. A randomized pretest post-test control group design was used to evaluate the effectiveness of a mail-out intervention for increasing screening mammography rates. A random sample of 802 women, 40+, residing in Los Angeles County, was surveyed by telephone at baseline and again 12 months after the intervention. RESULTS. Fifty percent of the intervention group and 56% of the control group had obtained a screening mammogram during the follow-up period. This difference was not statistically significant, indicating that the low-cost intervention was not successful in influencing screening mammography rates in this sample. In the combined intervention and control group, a stepwise logistic regression analysis revealed four baseline variables to be significant prospective predictors of mammography behavior during the follow-up period: Women who were adherent to the age-specific screening guidelines at baseline and women who had health insurance were more likely to obtain a mammogram during the follow-up, as were older women. Also, women who were greatly concerned about radiation exposure during a mammogram were about two and a half times less likely to obtain a mammogram during the follow-up than women who were less concerned. Self-reported reasons for adherence and nonadherence to screening guidelines are also described.