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Ates O, Pirlepesov F, Uh J, Hua CH, Merchant TE, Boria A, Davidoff AM, Graetz DE, Krasin MJ. Evaluating the Impact of Bowel Gas Variations for Wilms' Tumor in Pediatric Proton Therapy. Cancers (Basel) 2024; 16:642. [PMID: 38339393 PMCID: PMC10854738 DOI: 10.3390/cancers16030642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/27/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: Proton therapy, a precise form of radiation treatment, can be significantly affected by variations in bowel content. The purpose was to identify the most beneficial gantry angles that minimize deviations from the treatment plan quality, thus enhancing the safety and efficacy of proton therapy for Wilms' tumor patients. (2) Methods: Thirteen patients with Wilms' tumor, enrolled in the SJWT21 clinical trial, underwent proton therapy. The variations in bowel gas were systematically monitored using daily Cone Beam Computed Tomography (CBCT) imaging. Air cavities identified in daily CBCT images were analyzed to construct daily verification plans and measure water equivalent path length (WEPL) changes. A worst-case scenario simulation was conducted to identify the safest beam angles. (3) Results: The study revealed a maximum decrease in target dose (ΔD100%) of 8.0%, which corresponded to a WEPL variation (ΔWEPL) of 11.3 mm. The average reduction in target dose, denoted as mean ΔD100%, was found to be 2.8%, with a standard deviation (SD) of 3.2%. The mean ΔWEPL was observed as 3.3 mm, with an SD of 2.7 mm. The worst-case scenario analysis suggested that gantry beam angles oriented toward the patient's right and posterior aspects from 110° to 310° were associated with minimized WEPL discrepancies. (4) Conclusions: This study comprehensively evaluated the influence of bowel gas variability on treatment plan accuracy and proton range uncertainties in pediatric proton therapy for Wilms' tumor.
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Affiliation(s)
- Ozgur Ates
- St. Jude Children’s Research Hospital, Memphis, TN 38105, USA; (F.P.); (J.U.); (C.-h.H.); (T.E.M.); (A.B.); (A.M.D.); (D.E.G.); (M.J.K.)
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Duffy C, Graetz DE, Lopez AMZ, Carrillo AK, Job G, Chen Y, Devidas M, Leon SA, Bonzi SA, Flores PC, Torres LE, Broncano EH, Jaramillo SJ, Zelada MO, Novoa RR, Samudio A, Sánchez-Fernandez G, Villanueva E, Metzger ML, Friedrich P, Jeha S. Retrospective analysis of outcomes for pediatric acute lymphoblastic leukemia in South American centers. Front Oncol 2023; 13:1254233. [PMID: 38023200 PMCID: PMC10643117 DOI: 10.3389/fonc.2023.1254233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Acute lymphoblastic Leukemia (ALL) is the most common pediatric malignancy. While the survival rate for childhood ALL exceeds 90% in high-income countries, the estimated survival in low-and middle-income countries ranges from 22-79%, depending on the region and local resources. Methods This study retrospectively reviewed demographic, biological, and clinical parameters of children under 18 years of age with newly diagnosed ALL presenting between 2013-2017 across five pediatric centers in 4 countries in South America. Survival analyses were estimated using the Kaplan-Meier method. Results Across the five centers, 752 patients were analyzed (Bolivia [N=9], Ecuador [N=221], Paraguay [N=197], Peru [N=325]) and 92.1% (n=690) patients were diagnosed with B-cell and 7.5% (n= 56) with T-cell ALL. The median age was 5.5 years old (IQR 7.29). At diagnosis, 47.8% of patients were categorized as standard and 51.9% as high risk per their institutional regimen. Advanced diagnostics availability varied between modalities. MRD was evaluated in 69.1% of patients; molecular testing was available for ETV6-RUNX, BCR-ABL1, TCF3-PBX1, and KMT2A-rearranged ALL in 75-81% of patients; however, karyotyping and evaluation for iAMP21 were only performed in 42-61% of patients. Central nervous system (CNS) involvement was evaluated at diagnosis in 57.3% (n=429) patients; of these, 93.7% (n=402) were CNS 1, 1.6% (n=7) were CNS 2, 0.7% (n=11) were CNS3, 1.9% (n=8) had cranial nerve palsy, and 2.1% (n=9) results unavailable. Chemotherapy delays >2 weeks were reported in 56.0% (n=421) patients during treatment. Delays were attributed to infection in 63.2% (n=265), drug-related toxicities in 47.3% (n=198), and resource constraints, including lack of bed availability in 23.2% (n=97) of patients. The 3-year Abandonment-sensitive EFS and OS were 61.0±1.9% and 67.2±1.8%, respectively. The 3-year EFS and OS were 71.0±1.8% and 79.6±1.7%, respectively. Discussion This work reveals opportunities to improve survival, including addressing severe infections, treatment interruptions, and modifications due to drug shortages. In 2018, healthcare professionals across South America established the Pediatric Oncology Latin America (POLA) group in collaboration with St. Jude Children's Research Hospital. POLA collaborators developed an evidence-based, consensus-derived, adapted treatment guideline, informed by preliminary results of this evaluation, to serve as the new standard of care for pediatric ALL in participating institutions.
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Affiliation(s)
- Caitlyn Duffy
- St. Jude Children’s Research Hospital, Department of Global Pediatric Medicine, Memphis, TN, United States
| | - Dylan E. Graetz
- St. Jude Children’s Research Hospital, Department of Global Pediatric Medicine, Memphis, TN, United States
| | - Arturo M. Zapata Lopez
- Departamento de Oncología Pediátrica, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Angela K. Carrillo
- St. Jude Children’s Research Hospital, Department of Global Pediatric Medicine, Memphis, TN, United States
| | - Godwin Job
- St. Jude Children’s Research Hospital, Department of Global Pediatric Medicine, Memphis, TN, United States
| | - Yichen Chen
- St. Jude Children’s Research Hospital, Department of Global Pediatric Medicine, Memphis, TN, United States
| | - Meenakshi Devidas
- St. Jude Children’s Research Hospital, Department of Global Pediatric Medicine, Memphis, TN, United States
| | - Sandra Alarcón Leon
- Departamento de Oncología Pediátrica, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Sol Aponte Bonzi
- Departamento de Hemato Oncología Pediátrica, Hospital de Clínicas, Facultad de Ciencias Médicas, Universidad Nacional de Asunción, Asunción, Paraguay
| | - Pedro Cardona Flores
- Hospital Santa Cruz Caja Petrolera Salud (CPS), Hemato-Oncología Pediátrica, Santa Cruz, Bolivia
| | | | - Eddy Hernández Broncano
- Departamento de Oncología Pediátrica, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Soledad Jiménez Jaramillo
- La Sociedad de Lucha Contra el Cáncer (SOLCA) Núcleo de Loja, Oncohematóloga Pediatra, Loja, Ecuador
| | - Ma Ofelia Zelada
- Departamento de Hemato Oncología Pediátrica, Hospital de Clínicas, Facultad de Ciencias Médicas, Universidad Nacional de Asunción, Asunción, Paraguay
| | - Romulo Reaño Novoa
- Departamento de Oncología Pediátrica, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Angelica Samudio
- Departamento de Hemato Oncología Pediátrica, Hospital de Clínicas, Facultad de Ciencias Médicas, Universidad Nacional de Asunción, Asunción, Paraguay
| | | | - Erika Villanueva
- Hospital SOLCA Núcleo Quito, Hemato-Oncología Pediátrica, Quito, Ecuador
| | | | - Paola Friedrich
- St. Jude Children’s Research Hospital, Department of Global Pediatric Medicine, Memphis, TN, United States
| | - Sima Jeha
- St. Jude Children’s Research Hospital, Department of Global Pediatric Medicine, Memphis, TN, United States
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Rivera J, Malone S, Puerto-Torres M, Prewitt K, Counts L, Wiphatphumiprates P, Sakaan F, Al Zebin Z, Arias AV, Bhattacharyya P, Gunasekera S, Johnson S, Kambugu J, Kaye EC, Mandrell B, Mack J, McArthur J, Mendez A, Morrissey L, Sharara-Chami R, Snaman J, Sniderman E, Luke DA, Graetz DE, Agulnik A. CritCom: assessment of quality of interdisciplinary communication around deterioration in pediatric oncologic patients. Front Oncol 2023; 13:1207578. [PMID: 37886167 PMCID: PMC10598383 DOI: 10.3389/fonc.2023.1207578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 09/22/2023] [Indexed: 10/28/2023] Open
Abstract
Background High-quality clinical care requires excellent interdisciplinary communication, especially during emergencies, and no tools exist to evaluate communication in critical care. We describe the development of a pragmatic tool focusing on interdisciplinary communication during patient deterioration (CritCom). Methods The preliminary CritCom tool was developed after a literature review and consultation with a multidisciplinary panel of global experts in communication, pediatric oncology, and critical care to review the domains and establish content validity iteratively. Face and linguistic validity were established through cognitive interviews, translation, and linguistic synthesis. We conducted a pilot study among an international group of clinicians to establish reliability and usability. Results After reviewing 105 potential survey items, we identified 52 items across seven domains. These were refined through cognitive interviews with 36 clinicians from 15 countries. CritCom was piloted with 433 clinicians (58% nurses, 36% physicians, and 6% other) from 42 hospitals in 22 countries. Psychometric testing guided the refinement of the items for the final tool. CritCom comprised six domains with five items each (30 total). The final tool has excellent reliability (Cronbach's alpha 0.81-0.86), usability (93% agree or strongly agree that the tool is easy to use), and similar performance between English and Spanish tools. Confirmatory factor analysis was used to establish the final 6-domain structure. Conclusions CritCom is a reliable and pragmatic bilingual tool to assess the quality of interdisciplinary communication around patient deterioration for children in diverse resource levels globally. Critcom results can be used to design and evaluate interventions to improve team communication.
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Affiliation(s)
- Jocelyn Rivera
- Pediatric Emergency Department, Hospital Infantil Teletón de Oncología (HITO), Querétaro, Mexico
| | - Sara Malone
- Washington University in St. Louis, Brown School, St. Louis, MO, United States
| | - Maria Puerto-Torres
- Division of Critical Care Medicine, Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Kim Prewitt
- Washington University in St. Louis, Brown School, St. Louis, MO, United States
| | - Lara Counts
- Washington University in St. Louis, Brown School, St. Louis, MO, United States
| | - Parima Wiphatphumiprates
- Division of Critical Care Medicine, Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Firas Sakaan
- Division of Critical Care Medicine, Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Zebin Al Zebin
- Pediatric Hematology and Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Anita V. Arias
- Division of Critical Care Medicine, Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | | | - Sanjeeva Gunasekera
- Department of Pediatric Oncology National Cancer Institute, Maharagama, Sri Lanka
| | - Sherry Johnson
- Division of Critical Care Medicine, Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Joyce Kambugu
- Pediatric Oncology, Uganda Cancer Institute, Kampala, Uganda
| | - Erica C. Kaye
- Division of Critical Care Medicine, Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Belinda Mandrell
- Division of Critical Care Medicine, Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Jennifer Mack
- Department of Hematology and Oncology, Dana-Farber Cancer Institute and Boston Children’s Hospital, Boston, MA, United States
| | - Jennifer McArthur
- Division of Critical Care Medicine, Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Alejandra Mendez
- Pediatric Intensive Care Unit, Unidad Nacional de Oncología pediátrica (UNOP), Guatemala City, Guatemala
| | - Lisa Morrissey
- Department of Hematology and Oncology, Dana-Farber Cancer Institute and Boston Children’s Hospital, Boston, MA, United States
| | - Rana Sharara-Chami
- Pediatric Critical Care Medicine, American University of Beirut, Beirut, Lebanon
| | - Jennifer Snaman
- Department of Hematology and Oncology, Dana-Farber Cancer Institute and Boston Children’s Hospital, Boston, MA, United States
| | - Elizabeth Sniderman
- Northern Alberta Children’s Cancer Program, Stollery Children’s Hospital, Edmonton, AB, Canada
| | - Douglas A. Luke
- Washington University in St. Louis, Brown School, St. Louis, MO, United States
| | - Dylan E. Graetz
- Division of Critical Care Medicine, Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Asya Agulnik
- Division of Critical Care Medicine, Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
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Woo MC, Ferrara G, Puerto‐Torres M, Gillipelli SR, Elish P, Muniz‐Talavera H, Gonzalez‐Ruiz A, Armenta M, Barra C, Diaz‐Coronado R, Hernandez C, Juarez S, Loeza JDJ, Mendez A, Montalvo E, Peñafiel E, Pineda E, Graetz DE, Kortz T, Agulnik A. Stages of change: Strategies to promote use of a Pediatric Early Warning System in resource-limited pediatric oncology centers. Cancer Med 2023; 12:15358-15370. [PMID: 37403745 PMCID: PMC10417083 DOI: 10.1002/cam4.6087] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/25/2023] [Accepted: 05/04/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Pediatric Early Warning Systems (PEWS) assist early detection of clinical deterioration in hospitalized children with cancer. Relevant to successful PEWS implementation, the "stages of change" model characterizes stakeholder support for PEWS based on willingness and effort to adopt the new practice. METHODS At five resource-limited pediatric oncology centers in Latin America, semi-structured interviews were conducted with 71 hospital staff involved in PEWS implementation. Purposive sampling was used to select centers requiring variable time to complete PEWS implementation, with low-barrier centers (3-4 months) and high-barrier centers (10-11 months). Interviews were conducted in Spanish, professionally transcribed, and translated into English. Thematic content analysis explored "stage of change" with constant comparative analysis across stakeholder types and study sites. RESULTS Participants identified six interventions (training, incentives, participation, evidence, persuasion, and modeling) and two policies (environmental planning and mandates) as effective strategies used by implementation leaders to promote stakeholder progression through stages of change. Key approaches involved presentation of evidence demonstrating PEWS effectiveness, persuasion and incentives addressing specific stakeholder interests, enthusiastic individuals serving as models for others, and policies enforced by hospital directors facilitating habitual PEWS use. Effective engagement targeted hospital directors during early implementation phases to provide programmatic legitimacy for clinical staff. CONCLUSION This study identifies strategies to promote adoption and maintained use of PEWS, highlighting the importance of tailoring implementation strategies to the motivations of each stakeholder type. These findings can guide efforts to implement PEWS and other evidence-based practices that improve childhood cancer outcomes in resource-limited hospitals.
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Affiliation(s)
| | - Gia Ferrara
- St. Jude Children's Research HospitalMemphisTennesseeUSA
| | | | | | - Paul Elish
- Rollins School of Public HealthEmory UniversityAtlantaGeorgiaUSA
| | | | | | | | | | | | | | - Susana Juarez
- Hospital Central Dr. Ignacio Morones PrietoSan Luis PotosíMexico
| | | | | | | | | | - Estuardo Pineda
- Hospital Nacional de Niños Benjamín BloomSan SalvadorEl Salvador
| | | | - Teresa Kortz
- University of CaliforniaSan FranciscoCaliforniaUSA
| | - Asya Agulnik
- St. Jude Children's Research HospitalMemphisTennesseeUSA
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Malone S, Rivera J, Puerto-Torres M, Prewitt K, Sakaan F, Counts L, Al Zebin Z, Arias AV, Bhattacharyya P, Gunasekera S, Johnson S, Kambugu J, Kaye EC, Mandrell B, Mack JW, McArthur J, Mendez A, Morrissey L, Sharara-Chami R, Snaman J, Sniderman E, Luke DA, Graetz DE, Agulnik A. A new measure for multi-professional medical team communication: design and methodology for multilingual measurement development. Front Pediatr 2023; 11:1127633. [PMID: 37334217 PMCID: PMC10272604 DOI: 10.3389/fped.2023.1127633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/09/2023] [Indexed: 06/20/2023] Open
Abstract
Background As implementation science in global health continues to evolve, there is a need for valid and reliable measures that consider diverse linguistic and cultural contexts. A standardized, reproducible process for multilingual measure development may improve accessibility and validity by participants in global health settings. To address this need, we propose a rigorous methodology for multilingual measurement development. We use the example of a novel measure of multi-professional team communication quality, a determinant of implementation efforts. Methods The development and translation of this novel bilingual measure is comprised of seven steps. In this paper, we describe a measure developed in English and Spanish, however, this approach is not language specific. Participants are engaged throughout the process: first, an interprofessional panel of experts and second, through cognitive interviewing for measure refinement. The steps of measure development included: (1) literature review to identify previous measures of team communication; (2) development of an initial measure by the expert panel; (3) cognitive interviewing in a phased approach with the first language (English); (4): formal, forward-backward translation process with attention to colloquialisms and regional differences in languages; (5) cognitive interviewing repeated in the second language (Spanish); (6) language synthesis to refine both instruments and unify feedback; and (7) final review of the refined measure by the expert panel. Results A draft measure to assess quality of multi-professional team communication was developed in Spanish and English, consisting of 52 questions in 7 domains. This measure is now ready for psychometric testing. Conclusions This seven-step, rigorous process of multilingual measure development can be used in a variety of linguistic and resource settings. This method ensures development of valid and reliable tools to collect data from a wide range of participants, including those who have historically been excluded due to language barriers. Use of this method will increase both rigor and accessibility of measurement in implementation science and advance equity in research and practice.
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Affiliation(s)
- Sara Malone
- Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Jocelyn Rivera
- Department of Pediatrics, Hospital Infantil Teletón de Oncologia (HITO), Querétaro, Mexico
| | - Maria Puerto-Torres
- Division of Critical Care Medicine, Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Kim Prewitt
- Center for Public Health Systems Science, Washington University, St. Louis, MO, USA
| | - Firas Sakaan
- Division of Critical Care Medicine, Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Lara Counts
- Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Zebin Al Zebin
- Pediatric Hematology and Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Anita V Arias
- Division of Critical Care Medicine, Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | | | | | - Sherry Johnson
- Division of Critical Care Medicine, Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Joyce Kambugu
- Pediatric Oncology, Uganda Cancer Institute, Kampala, Uganda
| | - Erica C Kaye
- Division of Critical Care Medicine, Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Belinda Mandrell
- Division of Critical Care Medicine, Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Jennifer W Mack
- Department of Hematology and Oncology, Dana-Farber Cancer Institute and Boston Children's Hospital, Boston, MA, United States
| | - Jennifer McArthur
- Division of Critical Care Medicine, Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Alejandra Mendez
- Pediatric Intensive Care Unit, Unidad Nacional de Oncologia Pediatrica (UNOP), Guatemala City, Guatemala
| | - Lisa Morrissey
- Department of Hematology and Oncology, Dana-Farber Cancer Institute and Boston Children's Hospital, Boston, MA, United States
| | - Rana Sharara-Chami
- Pediatric Critical Care Medicine, American University of Beirut, Beirut, Lebanon
- Pediatric Intensive Care Unit, LJ Murphy Inova Children's Hospital, Fairfax, VA, United States
| | - Jennifer Snaman
- Department of Hematology and Oncology, Dana-Farber Cancer Institute and Boston Children's Hospital, Boston, MA, United States
| | - Elizabeth Sniderman
- Northern Alberta Children's Cancer Program, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Douglas A Luke
- Center for Public Health Systems Science, Washington University, St. Louis, MO, USA
| | - Dylan E Graetz
- Division of Critical Care Medicine, Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Asya Agulnik
- Division of Critical Care Medicine, Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
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Graetz DE. The most vulnerable pediatric cancer patients. The Lancet Regional Health - Americas 2023; 21:100480. [PMID: 37008198 PMCID: PMC10064219 DOI: 10.1016/j.lana.2023.100480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 03/28/2023]
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Graetz DE, Chen Y, Devidas M, Antillon-Klussmann F, Fu L, Quintero K, Fuentes-Alabi SL, Gassant PY, Kaye EC, Baker JN, Rodriguez Galindo C, Mack JW. Interdisciplinary care of pediatric oncology patients: A survey of clinicians in Central America and the Caribbean. Pediatr Blood Cancer 2023; 70:e30244. [PMID: 36788461 DOI: 10.1002/pbc.30244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/26/2022] [Accepted: 01/22/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Quality cancer care depends on interdisciplinary communication. This study explored the communication practices of interdisciplinary clinicians, the types of healthcare services for which they engage in interdisciplinary collaboration, and the association between interdisciplinary care and perceived quality of care, as well as job satisfaction. METHODS We conducted a survey of interdisciplinary clinicians from cancer centers in Guatemala, Honduras, Panama, El Salvador, and Haiti. The survey included 68 items including previously validated tools and novel questions. RESULTS Total 174 interdisciplinary clinicians completed the survey: nurses (n = 60), medical subspecialists (n = 35), oncologists (n = 22), psychosocial providers (n = 20), surgeons (n = 12), pathologists (n = 9), radiologists (n = 9), and radiation oncologists (n = 5). Oncologists reported daily communication with nurses (95%) and other oncologists (91%). While 90% of nurses reported daily communication with other nurses, only 66% reported daily communication with oncologists, and more than 50% of nurses reported never talking to pathologists, radiologists, radiation oncologists, or surgeons. Most clinicians described interdisciplinary establishment of cancer treatment goals and prognosis (84%), patient preferences (81%), and determination of first treatment modality (80%). Clinicians who described more interdisciplinary collaboration had higher job satisfaction (p = .04) and perceived a higher level of overall quality of care (p = .004). CONCLUSIONS Clinicians in these limited resource settings describe strong interdisciplinary collaboration contributing to higher job satisfaction and perceived quality of care. However, nurses in these settings reported more limited interdisciplinary communication and care. Additional studies are necessary to further define clinical roles on interdisciplinary care teams and their associations with patient outcomes.
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Affiliation(s)
- Dylan E Graetz
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Yichen Chen
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | - Federico Antillon-Klussmann
- Unidad Nacional de Oncología Pediátrica, Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | - Ligia Fu
- Hospital Escuela de Tegucigalpa, Tegucigalpa, Honduras
| | - Karina Quintero
- Children's Hospital Dr Jose Renan Esquivel, Panama City, Panama
| | - Soad L Fuentes-Alabi
- Hospital Nacional de Niños Benjamin Bloom, Fundación Ayudame a Vivir, El Salvador City, El Salvador
| | | | - Erica C Kaye
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Justin N Baker
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | - Jennifer W Mack
- Dana Farber Cancer Institute/Boston Children's Hospital, Boston, Massachusetts, USA
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Ferrara G, Aguina M, Mirochnick E, Wiphatphumiprates P, Moreira DC, Sniderman E, Villegas CA, Kaye EC, Ragab I, Maliti B, Naidu G, Gassant PY, Arce D, Arora RS, Alcasabas AP, Raza MR, Velasco P, Kambugu J, Vinitsky A, Rodriguez Galindo C, Agulnik A, Graetz DE. Communication transforms the impact of the COVID-19 pandemic on children with cancer and their families. Cancer Med 2023. [PMID: 37081718 DOI: 10.1002/cam4.5950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/15/2023] [Accepted: 04/02/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic altered healthcare systems globally, causing delays in care delivery and increased anxiety among patients and families. This study examined how hospital stakeholders and clinicians perceived the global impact of the COVID-19 pandemic on children with cancer and their families. METHODS This secondary analysis examined data from a qualitative study consisting of 19 focus groups conducted in 8 languages throughout 16 countries. A codebook was developed with novel codes derived inductively from transcript review. In-depth analysis focused on the impact of the COVID-19 pandemic on children with cancer and their families. RESULTS Eight themes describing the impact of the pandemic on patients and their families were identified and classified into three domains: contributing factors (COVID-19 Policies, Cancer Treatment Modifications, COVID-19 Symptoms, Beliefs), patient-related impacts (Quality of Care, Psychosocial impacts, Treatment Reluctance), and the central transformer (Communication). Participants described the ability of communication to transform the effect of contributing factors on patient-related impacts. The valence of impacts depended on the quality and quantity of communication among clinicians and between clinicians and patients and families. CONCLUSIONS Communication served as the central factor impacting whether the COVID-19 pandemic positively or negatively affected children with cancer and families. These findings emphasize the key role communication plays in delivering patient-centered care and can guide future development of communication-centered interventions globally.
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Affiliation(s)
- Gia Ferrara
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Molly Aguina
- Princeton University, Princeton, New Jersey, USA
| | - Emily Mirochnick
- The Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | | | | | - Elizabeth Sniderman
- Northern Alberta Children's Cancer Program, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | | | - Erica C Kaye
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Iman Ragab
- Ain Shams University, Children's Hospital, Hematology-Oncology Unit, Cairo, Egypt
| | | | - Gita Naidu
- Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Daniela Arce
- Hospital Pediátrico de Sinaloa, Culiacan, Mexico
| | | | | | | | - Pablo Velasco
- Pediatric Oncology and Hematology Department, Vall d'Hebron Hospital, Barcelona, Spain
| | | | - Anna Vinitsky
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | - Asya Agulnik
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Dylan E Graetz
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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9
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Wiphatphumiprates PP, Graetz DE, Ferrara G, Puerto-Torres M, Gillipelli SR, Elish P, Muniz-Talavera H, Gonzalez-Ruiz A, Armenta M, Barra C, Carpio Z, Hernandez C, Juarez S, de Jesus Loeza J, Mendez A, Montalvo E, Penafiel E, Pineda E, McKay V, Agulnik A. The COVID-19 Pandemic's impact on sustainability and expansion of a Pediatric Early Warning System in resource-limited hospitals. Cancer Med 2023. [PMID: 37022012 DOI: 10.1002/cam4.5876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 03/11/2023] [Accepted: 03/16/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic impacted healthcare delivery worldwide, including pediatric cancer care, with a disproportionate effect in resource-limited settings. This study evaluates its impact on existing quality improvement (QI) programs. METHODS We conducted 71 semi-structured interviews of key stakeholders at five resource-limited pediatric oncology centers participating in a collaborative to implement Pediatric Early Warning System (PEWS). Interviews were conducted virtually using a structured interview guide, recorded, transcribed, and translated into English. Two coders developed a codebook of a priori and inductive codes and independently coded all transcripts, achieving a kappa of 0.8-0.9. Thematic analysis explored the impact of the pandemic on PEWS. RESULTS All hospitals reported limitations in material resources, reduction in staffing, and impacts on patient care due to the pandemic. However, the impact on PEWS varied across centers. Identified factors that promoted or limited ongoing PEWS use included the availability of material resources needed for PEWS, staff turnover, PEWS training for staff, and the willingness of staff and hospital leaders to prioritize PEWS. Consequently, some hospitals were able to sustain PEWS; others halted or reduced PEWS use to prioritize other work. Similarly, the pandemic delayed plans at all hospitals to expand PEWS to other units. Several participants were hopeful for future expansion of PEWS post-pandemic. CONCLUSION The COVID-19 pandemic created challenges for sustainability and scale of PEWS, an ongoing QI program, in these resource-limited pediatric oncology centers. Several factors mitigated these challenges and promoted ongoing PEWS use. These results can guide strategies to sustain effective QI interventions during future health crises.
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Affiliation(s)
| | - Dylan E Graetz
- Global Pediatric Medicine at St. Jude Children's Research Hospital, Tennessee, Memphis, USA
| | - Gia Ferrara
- Global Pediatric Medicine at St. Jude Children's Research Hospital, Tennessee, Memphis, USA
| | - Maria Puerto-Torres
- Global Pediatric Medicine at St. Jude Children's Research Hospital, Tennessee, Memphis, USA
| | | | - Paul Elish
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | | | - Miriam Armenta
- Pediatric Oncology, Hospital General de Tijuana, Tijuana, Mexico
| | - Camila Barra
- Pediatric Oncology, Hospital Dr. Luis Calvo Mackenna, Santiago, Chile
| | - Zulma Carpio
- Pediatric Oncology, Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Cinthia Hernandez
- Pediatric Oncology, Hospital Infantil Teletón de Oncología, Querétaro, Mexico
| | - Susana Juarez
- Pediatrics, Hospital Central Dr. Ignacio Morones Prieto, San Luis Potosí, Mexico
| | | | - Alejandra Mendez
- Pediatric Critical Care, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Erika Montalvo
- Pediatric Critical Care, Hospital Oncológico Solca Núcleo de Quito, Quito, Ecuador
| | - Eulalia Penafiel
- Pediatric Oncology, Instituto del Cáncer SOLCA Cuenca, Cuenca, Ecuador
| | - Estuardo Pineda
- Pediatric Oncology, Hospital Nacional de Niños Benjamín Bloom, San Salvador, El Salvador
| | - Virginia McKay
- Bloom School of Medicine, Washington University, St. Louis, Missouri, USA
| | - Asya Agulnik
- Global Pediatric Medicine at St. Jude Children's Research Hospital, Tennessee, Memphis, USA
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10
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Williams AH, Rivas S, Fuentes L, Cáceres‐Serrano A, Ferrara G, Reeves T, Antillon‐Klussmann F, Rodriguez‐Galindo C, Mack JW, Graetz DE. Understanding hope at diagnosis: A study among Guatemalan parents of children with cancer. Cancer Med 2023; 12:9966-9975. [PMID: 36846975 PMCID: PMC10166945 DOI: 10.1002/cam4.5725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/05/2023] [Accepted: 02/10/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND In high-income countries, hope facilitates parental coping and builds the clinical relationship between families of children with cancer and their clinicians. However, the manifestation of hope in low- and middle-income countries (LMICs) remains poorly understood. Our study explores Guatemalan parents' experiences with hope during the pediatric oncology diagnostic process and aims to identify discrete actions clinicians take to support hope. METHODS This qualitative study utilized audio-recordings of the diagnostic process and an additional semi-structured interview for 20 families of children with cancer at Unidad Nacional de Oncología Pediátrica in Guatemala. Spanish audio-recordings were translated into English, transcribed, and coded using a priori and novel codes. Thematic content analysis using constant comparative methods explored parents' hopes and concerns. RESULTS At diagnosis, Guatemalan parents expressed both hopes and concerns related to the entire cancer continuum. Throughout the diagnostic process, hope grew as concerns were alleviated. Clinicians supported hope by creating a supportive environment, providing information, affirming religious beliefs, and empowering parents. These strategies helped parents shift their focus from fear and uncertainty toward hope for their child's future. Parents expressed that establishing hope improved mood, promoted acceptance, and enabled them to care for themselves and their children. CONCLUSION These results confirm the relevance of supporting hope in pediatric oncology settings in LMICs and suggest that culture informs hope-related needs. Supporting hope is critical across cultures and can be integrated into clinical conversation using the four processes identified by our results.
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Affiliation(s)
| | - Silvia Rivas
- Unidad Nacional de Oncología PediátricaGuatemala CityGuatemala
| | - Lucia Fuentes
- Unidad Nacional de Oncología PediátricaGuatemala CityGuatemala
| | | | - Gia Ferrara
- St. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Tegan Reeves
- St. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Federico Antillon‐Klussmann
- Unidad Nacional de Oncología PediátricaGuatemala CityGuatemala
- Francisco Marroquin University School of MedicineGuatemala CityGuatemala
| | | | - Jennifer W. Mack
- Dana Farber Cancer Institute/Boston Children's HospitalBostonMassachusettsUSA
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11
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Abutineh F, Graetz DE, Muniz-Talavera H, Ferrara G, Puerto-Torres M, Chen Y, Gillipelli SR, Elish P, Gonzalez-Ruiz A, Alfonso Carreras Y, Alvarez S, Arce Cabrera D, Arguello Vargas D, Armenta Cruz M, Barra C, Calderon Sotelo P, Carpio Z, Chavez Rios M, Covarrubias D, de Leon Vasquez L, Diaz Coronado R, Fing Soto EA, Gomez-Garcia W, Hernandez C, Juarez Tobias MS, Leon E, Loeza Oliva JDJ, Mendez A, Miller K, Montalvo Cozar E, Negroe Ocampo NDC, Penafiel E, Pineda E, Rios L, Rodriguez Ordonez E, Soto Chavez V, Devidas M, Agulnik A. Impact of hospital characteristics on implementation of a Pediatric Early Warning System in resource-limited cancer hospitals. Front Oncol 2023; 13:1122355. [PMID: 37207162 PMCID: PMC10189109 DOI: 10.3389/fonc.2023.1122355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/17/2023] [Indexed: 05/21/2023] Open
Abstract
Background Pediatric Early Warning Systems (PEWS) aid in identification of deterioration in hospitalized children with cancer but are underutilized in resource-limited settings. Proyecto EVAT is a multicenter quality improvement (QI) collaborative in Latin America to implement PEWS. This study investigates the relationship between hospital characteristics and time required for PEWS implementation. Methods This convergent mixed-methods study included 23 Proyecto EVAT childhood cancer centers; 5 hospitals representing quick and slow implementers were selected for qualitative analysis. Semi-structured interviews were conducted with 71 stakeholders involved in PEWS implementation. Interviews were recorded, transcribed and translated to English, then coded using a priori and novel codes. Thematic content analysis explored the impact of hospital characteristics and QI experience on time required for PEWS implementation and was supplemented by quantitative analysis exploring the relationship between hospital characteristics and implementation time. Results In both quantitative and qualitative analysis, material and human resources to support PEWS significantly impacted time to implementation. Lack of resources produced various obstacles that extended time necessary for centers to achieve successful implementation. Hospital characteristics, such as funding structure and type, influenced PEWS implementation time by determining their resource-availability. Prior hospital or implementation leader experience with QI, however, helped facilitate implementation by assisting implementers predict and overcome resource-related challenges. Conclusions Hospital characteristics impact time required to implement PEWS in resource-limited childhood cancer centers; however, prior QI experience helps anticipate and adapt to resource challenges and more quickly implement PEWS. QI training should be a component of strategies to scale-up use of evidence-based interventions like PEWS in resource-limited settings.
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Affiliation(s)
- Farris Abutineh
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Dylan E. Graetz
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Hilmarie Muniz-Talavera
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Gia Ferrara
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Maria Puerto-Torres
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Yichen Chen
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | | | - Paul Elish
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | | | | | - Shillel Alvarez
- Pediatric Oncology, Benemérito Hospital General con Especialidades “Juan María de Salvatierr”, La Paz, Mexico
| | - Daniela Arce Cabrera
- Pediatric Hemato-Oncology Unit, Hospital Pediatrico de Sinaloa, Culiacan, Mexico
| | | | | | - Camila Barra
- Pediatric Oncology, Centro de Investigacion Bradford Hill, Santiago, Chile
| | | | - Zulma Carpio
- Pediatric Oncology, Instituto Nacional de Enfermedades Neoplasticas, Lima, Peru
| | | | - Daniela Covarrubias
- Pediatric Oncology, Centro Estatal de Oncología de Campeche, Campeche, Mexico
| | - Lucy de Leon Vasquez
- Pediatric Oncology, Hospital Infantil Regional Universitario Dr. Arturo Grullon, Santiago, Dominican Republic
| | | | | | - Wendy Gomez-Garcia
- Oncology Unit, Hospital Infantil Dr. Robert Reid Cabral, Santo, Domingo, Dominican Republic
| | | | | | - Esmeralda Leon
- Medical Oncology, Hospital Guillermo Almenara Irigoyen, Lima, Peru
| | | | - Alejandra Mendez
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Kenia Miller
- Pediatric Hemato-Oncology, Hospital del Niño “Jose Renan Esquivel”, Panama City, Panama
| | - Erika Montalvo Cozar
- Pediatric Intensive Care Unit, Hospital Oncológico Solca Núcleo de Quito, Quito, Ecuador
| | | | - Eulalia Penafiel
- Pediatric Oncology, Instituto del Cáncer SOLCA Cuenca, Cuenca, Ecuador
| | - Estuardo Pineda
- Pediatric Hemato-Oncology, Hospital Nacional de Niños Benjamín Bloom, San Salvador, El Salvador
| | - Ligia Rios
- Pediatric Hemato-Oncology, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | | | | | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
- *Correspondence: Asya Agulnik,
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12
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Bolous NS, Graetz DE, Ashrafian H, Barlow J, Bhakta N, Sounderajah V, Dowdeswell B. Harnessing a clinician-led governance model to overcome healthcare tribalism and drive innovation: a case study of Northumbria NHS Foundation Trust. J Health Organ Manag 2022; ahead-of-print:1-16. [PMID: 36520658 PMCID: PMC10430796 DOI: 10.1108/jhom-05-2022-0157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 05/26/2022] [Accepted: 10/04/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Healthcare tribalism refers to the phenomenon through which different groups in a healthcare setting strictly adhere to their profession-based silo, within which they exhibit stereotypical behaviours. In turn, this can lead to deleterious downstream effects upon productivity and care delivered to patients. This study highlights a clinician-led governance model, implemented at a National Health Service (NHS) trust, to investigate whether it successfully overcame tribalism and helped drive innovation. DESIGN/METHODOLOGY/APPROACH This was a convergent mixed-methods study including qualitative and quantitative data collected in parallel. Qualitative data included 27 semi-structured interviews with representatives from four professional groups. Quantitative data were collected through a verbally administered survey and scored on a 10-point scale. FINDINGS The trust arranged its services under five autonomous business units, with a clinician and a manager sharing the leadership role at each unit. According to interviewees replies, this equivalent authority was cascaded down and enabled breaking down professional siloes, which in turn aided in the adoption of an innovative clinical model restructure. PRACTICAL IMPLICATIONS This study contributes to the literature by characterizing a real-world example in which healthcare tribalism was mitigated while reflecting on the advantages yielded as a result. ORIGINALITY/VALUE Previous studies from all over the world identified major differences in the perspectives of different healthcare professional groups. In the United Kingdom, clinicians largely felt cut off from decision-making and dissatisfied with their managerial role. The study findings explain a governance model that allowed harmony and inclusion of different professions. Given the long-standing strains on healthcare systems worldwide, stakeholders can leverage the study findings for guidance in developing and implementing innovative managerial approaches.
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Affiliation(s)
- Nancy S. Bolous
- Department of Global Pediatric Medicine
,
St Jude Children’s Research Hospital
, Memphis, Tennessee,
USA
| | - Dylan E. Graetz
- Department of Global Pediatric Medicine
,
St Jude Children’s Research Hospital
, Memphis, Tennessee,
USA
| | - Hutan Ashrafian
- Institute of Global Health Innovation, Imperial College London
, London,
UK
- Department of Surgery and Cancer,
Imperial College London
, London,
UK
| | - James Barlow
- Business School,
Imperial College London
, London,
UK
| | - Nickhill Bhakta
- Department of Global Pediatric Medicine
,
St Jude Children’s Research Hospital
, Memphis, Tennessee,
USA
| | - Viknesh Sounderajah
- Institute of Global Health Innovation, Imperial College London
, London,
UK
- Department of Surgery and Cancer,
Imperial College London
, London,
UK
| | - Barrie Dowdeswell
- Management Center Innsbruck, Internationale Hochschule GmbH
, Innsbruck,
Austria
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13
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Mirochnick E, Graetz DE, Ferrara G, Puerto-Torres M, Gillipelli SR, Elish P, Muniz-Talavera H, Gonzalez-Ruiz A, Armenta M, Barra C, Diaz-Coronado R, Hernandez C, Juarez S, Loeza JDJ, Mendez A, Montalvo E, Penafiel E, Pineda E, Agulnik A. Multilevel impacts of a pediatric early warning system in resource-limited pediatric oncology hospitals. Front Oncol 2022; 12:1018224. [PMID: 36313665 PMCID: PMC9597682 DOI: 10.3389/fonc.2022.1018224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/26/2022] [Indexed: 11/24/2022] Open
Abstract
Background Pediatric Early Warning Systems (PEWS) reduce clinical deterioration, improve interdisciplinary communication, and provide cost savings; however, little is known about how these impacts are achieved or related. This study evaluates the multi-level impacts of PEWS in resource-limited pediatric oncology centers. Methods We conducted 71 semi-structured interviews including physicians (45%), nurses (45%), and administrators (10%) from 5 resource-limited pediatric oncology centers in 4 Latin American countries. Interviews were conducted in Spanish, transcribed, and translated into English. A code book was developed using a priori and inductively derived codes. Transcripts were independently coded by 2 coders, achieving a kappa of 0.8-0.9. Thematic content analysis explored perceived impacts of PEWS at the level of the patient, clinician, healthcare team, and institution. Results PEWS improved the quality of attention for patients, reducing morbidity and mortality. Clinicians felt more knowledgeable, confident, and empowered providing patient care, resulting in greater job satisfaction. PEWS affected team dynamics by improving interdisciplinary (ward and intensive care unit) and interprofessional (physicians and nurses) relationships and communication. This ultimately led to institutional culture change with emphasis on patient safety, collaboration with other centers, and receipt of institutional awards. Together, these impacts led to hospital-wide support of ongoing PEWS use. Conclusions In resource-limited hospitals, PEWS use results in multi-level positive impacts on patients, clinicians, teams, and institutions, creating a feedback loop that further supports ongoing PEWS use. These findings can guide advocacy for PEWS to various stakeholders, improve PEWS effectiveness, and inform assessment of other interventions to improve childhood cancer outcomes.
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Affiliation(s)
- Emily Mirochnick
- The Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States
| | - Dylan E. Graetz
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Gia Ferrara
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Maria Puerto-Torres
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Srinithya R. Gillipelli
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
- School of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Paul Elish
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Hilmarie Muniz-Talavera
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Alejandra Gonzalez-Ruiz
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Miriam Armenta
- Pediatric Oncology, Hospital General de Tijuana, Tijuana, Mexico
| | - Camila Barra
- Pediatric Oncology, Hospital Dr. Luis Calvo Mackenna, Santiago, Chile
| | | | - Cinthia Hernandez
- Pediatric Oncology, Hospital Infantil Teletón de Oncología, Querétaro, Mexico
| | - Susana Juarez
- Pediatrics, Hospital Central Dr. Ignacio Morones Prieto, San Luis Potosí, Mexico
| | | | - Alejandra Mendez
- Pediatric Critical Care, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Erika Montalvo
- Pediatric Critical Care, Hospital Oncológico Solca Núcleo de Quito, Quito, Ecuador
| | - Eulalia Penafiel
- Pediatric Oncology, Instituto del Cáncer Solca Cuenca, Cuenca, Ecuador
| | - Estuardo Pineda
- Pediatric Oncology, Hospital Nacional de Niños Benjamín Bloom, San Salvador, El Salvador
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
- *Correspondence: Asya Agulnik,
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14
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Graetz DE, Rivas SE, Fuentes AL, Caceres-Serrano A, Antillon-Klussmann F, Rodriguez-Galindo C, Mack JW. Development and Adaptation of a Patient-Centered Communication Survey for Parents of Children With Cancer in Guatemala. JCO Glob Oncol 2022; 8:e2200124. [PMID: 36179269 PMCID: PMC9812448 DOI: 10.1200/go.22.00124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Surveys to assess patient and family experiences of pediatric cancer care have been primarily developed and validated in high-income Western settings with English-speaking participants. However, 90% of children with cancer live in low- and middle-income countries. We sought to develop a survey focused on pediatric cancer communication for use in a low-literacy population in Guatemala, including adaptation of many previously validated items. METHODS A multidisciplinary team developed a quantitative survey on the basis of a theoretical model of important components and influences on pediatric cancer communication. The original survey included established items previously used in high-income settings and novel questions designed for this study. The survey was translated into Spanish and pilot tested with parents of children receiving treatment at Unidad Nacional de Oncologia Pediatrica in Guatemala City, Guatemala, from April-June 2019. Cognitive interviews were used during pilot testing, and the survey was iteratively revised throughout this process. RESULTS Early in testing, Guatemalan parents tended to choose answers at the extreme ends of response categories and socially desirable responses. Ultimately, a visual aid was developed to accompany three-item Likert scale response options. This allowed for successful administration of the survey instrument, resulting in moderate variation of response options and similar proportions to those generated when the original five-item responses were used in parent populations from the United States. CONCLUSION Appropriately adapted surveys are necessary to understand patient-centered communication among pediatric oncology populations in low- and middle-income countries. Eventual validation of such tools will enable cross-cultural studies and comparative analysis of results.
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Affiliation(s)
- Dylan E. Graetz
- St Jude Children's Research Hospital, Memphis, TN,Dylan E. Graetz, MD, MPH, St Jude Children's Research Hospital, 262 Danny Thomas Place, Mailstop 721, Memphis, TN 38105-3678; Twitter: @DylanGraetzMD; e-mail:
| | | | | | | | - Federico Antillon-Klussmann
- Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala,Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | | | - Jennifer W. Mack
- Dana Farber Cancer Institute/Boston Children's Hospital, Boston, MA
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15
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Gillipelli SR, Kaye EC, Garza M, Ferrara G, Rodriguez M, Soberanis Vasquez DJ, Mendez Aceituno A, Antillón‐Klussmann F, Gattuso JS, Mandrell BN, Baker JN, Rodriguez‐Galindo C, Agulnik A, Graetz DE. Pediatric Early Warning Systems (PEWS) improve provider-family communication from the provider perspective in pediatric cancer patients experiencing clinical deterioration. Cancer Med 2022; 12:3634-3643. [PMID: 36128882 PMCID: PMC9939098 DOI: 10.1002/cam4.5210] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 08/05/2022] [Accepted: 08/24/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Communication between providers and patients' families is an integral part of clinical care. Family concern is a validated component of Pediatric Early Warning Systems (PEWS); however, little is known about the impact of PEWS on provider-family communication. METHODS Semi-structured interviews were conducted with 83 ward and Pediatric Intensive Care Unit (PICU) providers involved in the care of patients with deterioration at two pediatric oncology hospitals of different resource levels: St. Jude Children's Research Hospital (n = 42) in the United States and Unidad Nacional de Oncología Pediátrica (UNOP, n = 41) in Guatemala. Interviews were conducted in the participants' native language (English or Spanish), transcribed, and translated into English. Transcripts were coded by two researchers and analyzed for thematic content surrounding family communication and concern. RESULTS All participants recognized patients' families as a valuable part of the care team, particularly during events requiring escalation of care. Perceived barriers to communication included limited time spent at the bedside, and, at UNOP, language and literacy challenges which occasionally limited providers' ability to assess family concern and involve families in patient care. Despite these barriers, providers perceived PEWS improved communication by facilitating more interaction with families, allowing for relationship-building, anticipatory guidance, and destigmatization of the PICU. PEWS assessments also allowed families to contribute to identification of deterioration. CONCLUSIONS PEWS improve the quality of communication between providers and families by providing more opportunities for interaction, building relationships, and trust. These findings further support the use of PEWS in the care of children with cancer in hospitals of all resource-levels.
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Affiliation(s)
- Srinithya R. Gillipelli
- Baylor College of MedicineHoustonTexasUSA,Department of Global Pediatric MedicineSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Erica C. Kaye
- Division of Quality of Life and Palliative CareSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Marcela Garza
- Department of Global Pediatric MedicineSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Gia Ferrara
- Department of Global Pediatric MedicineSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Mario Rodriguez
- Department of OncologyUnidad Nacional de Oncología PediátricaGuatemala CityGuatemala
| | | | | | - Federico Antillón‐Klussmann
- Department of OncologyUnidad Nacional de Oncología PediátricaGuatemala CityGuatemala,School of MedicineFrancisco Marroquin UniversityGuatemala CityGuatemala
| | - Jami S. Gattuso
- Department of Nursing ResearchSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Belinda N. Mandrell
- Department of Nursing ResearchSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Justin N. Baker
- Division of Quality of Life and Palliative CareSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | | | - Asya Agulnik
- Department of Global Pediatric MedicineSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Dylan E. Graetz
- Department of Global Pediatric MedicineSt. Jude Children's Research HospitalMemphisTennesseeUSA
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16
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Graetz DE, Rivas S, Wang H, Vedaraju Y, Ferrara G, Fuentes L, Cáceres-Serrano A, Antillon-Klussmann F, Devidas M, Metzger M, Rodriguez-Galindo C, Mack JW. Cancer treatment decision-making among parents of paediatric oncology patients in Guatemala: a mixed-methods study. BMJ Open 2022; 12:e057350. [PMID: 35953257 PMCID: PMC9379539 DOI: 10.1136/bmjopen-2021-057350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To examine treatment decision-making priorities and experiences among parents of children with cancer in Guatemala. SETTING This study was conducted at Guatemala's National Pediatric Cancer Center in Guatemala City. PARTICIPANTS Spanish-speaking parents of paediatric patients (≤18 years of age) diagnosed with any form of cancer within the 8 weeks prior to study enrolment. The quantitative portion of this study included 100 parent participants; the qualitative component included 20 parents. Most participants were Catholic or Evangelical Spanish-speaking mothers. OUTCOMES Priorities and experiences of cancer treatment decision-making including decision-making role and experienced regret. RESULTS A range of paediatric ages and cancer diagnoses were included. Most Guatemalan parents surveyed (70%) made decisions about their child's cancer together and almost all (94%) without input from their community. Surveyed parents predominately preferred shared decision-making with their child's oncologist (76%), however 69% agreed it was best not to be provided with many options. Two-thirds of surveyed parents (65%) held their preferred role in decision-making, with fathers more likely to hold their preferred role than mothers (p=0.02). A small number of parents (11%) experienced heightened decisional regret, which did not correlate with socio-demographic characteristics or preferred decision-making role. Qualitative results supported quantitative findings, demonstrating a decision-making process that emphasised trust and honesty. CONCLUSIONS Guatemalan parents preferred to make decisions with their medical team and appreciated providers who were honest and inclusive, but directive about decisions. This study reinforces the importance of the provider-parent relationship and encourages clinicians in all settings to ask about and honour each parent's desired role in decision-making.
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Affiliation(s)
- Dylan E Graetz
- Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Silvia Rivas
- Unidad Nacional de Oncologia Pediatrica, Guatemala City, Guatemala
| | - Huiqi Wang
- Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Yuvanesh Vedaraju
- Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Gia Ferrara
- Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Lucia Fuentes
- Department of Psychology, Unidad Nacional de Oncologia Pediatrica, Guatemala City, Guatemala
| | - Ana Cáceres-Serrano
- Department of Psychology, Unidad Nacional de Oncologia Pediatrica, Guatemala City, Guatemala
| | - Federico Antillon-Klussmann
- Unidad Nacional de Oncologia Pediatrica, Guatemala City, Guatemala
- Universidad Francisco Marroquin Facultad de Medicina, Guatemala City, Guatemala
| | - Meenakshi Devidas
- Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Monika Metzger
- Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | - Jennifer W Mack
- Department of Population Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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17
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McNeil MJ, Ehrlich BS, Wang H, Vedaraju Y, Bustamante M, Dussel V, Friedrich P, Garcia Quintero X, Gillipelli SR, Gomez Garcia W, Graetz DE, Kaye EC, Metzger ML, Sabato Danon CV, Devidas M, Baker JN, Agulnik A. Physician Perceptions of Palliative Care for Children With Cancer in Latin America. JAMA Netw Open 2022; 5:e221245. [PMID: 35258577 PMCID: PMC8905380 DOI: 10.1001/jamanetworkopen.2022.1245] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE The World Health Organization (WHO) designates early integration of palliative care as an ethical responsibility in the treatment of children with serious illness. Although structural barriers may influence provision of pediatric palliative care (PPC) for children with cancer in resource-limited settings, underlying physician perceptions may also impede early integration of PPC in cancer care. OBJECTIVE To investigate perceptions among physicians in Latin America about the integration of palliative care for children with cancer. DESIGN, SETTING, AND PARTICIPANTS This survey study used the Assessing Doctors' Attitudes on Palliative Treatment (ADAPT) survey, which was developed for physicians who care for children with cancer and was initially distributed in Eurasia. The survey was modified for use in Latin America, including translation into Spanish and adaptation for cultural context. The survey was distributed between August 21, 2020, and January 31, 2021, to physicians treating children with cancer in 17 Latin American countries. Each country had a specific survey distribution method based on guidance of local experts. MAIN OUTCOMES AND MEASURES The ADAPT survey evaluated physicians' understanding of palliative care principles, comfort in addressing patient and family suffering, and identification of barriers to PPC integration for children with cancer. Univariate and multivariable linear regression analyses were used to assess factors associated with physicians' knowledge about and comfort with PPC practice and whether independent physician variables were associated with survey response alignment with WHO guidance on PPC. Open-ended questions were analyzed qualitatively to supplement the quantitative data. RESULTS A total of 874 physicians from 17 countries participated, with an overall response rate of 39.9% (874 of 2193) and a median country response rate of 51.4% (range, 23.7%-100%). Most respondents were aged 35 years or older (577 [66.0%]), and 594 (68.0%) identified as female. Most physicians (486 [55.6%]) had no formal PPC training, and 303 (34.7%) had no access to PPC experts for consultation. Physician perspectives on PPC were generally aligned with WHO guidance (mean [SD] alignment, 83.0% [14.1%]; range among respondents, 24.0%-100%). However, only 438 respondents (50.1%) felt comfortable addressing physical symptoms of patients receiving PPC, 295 (33.8%) felt comfortable addressing emotional symptoms, and 216 (24.7%) felt comfortable addressing grief and bereavement needs of the patient's family. A total of 829 participants (94.8%) desired further education and training in PPC. CONCLUSION AND RELEVANCE Although physicians' perspectives aligned well with WHO guidance for PPC, this survey study identified opportunities for improving physician training in symptom management and emotional support for children with cancer and their families. These findings may inform the development of targeted interventions to improve the quality of PPC for children with cancer in Latin America.
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Affiliation(s)
- Michael J. McNeil
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
- Division of Quality of Life and Palliative Care Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Bella S. Ehrlich
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
- Brown University School of Medicine, Providence, Rhode Island
| | - Huiqi Wang
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Yuvanesh Vedaraju
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | | | - Veronica Dussel
- Center for Research and Implementation in Palliative Care, Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Paola Friedrich
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Ximena Garcia Quintero
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
- Fundación Valle de Lilli, Cali, Colombia
| | - Srinithya R. Gillipelli
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
- Baylor College of Medicine, Houston, Texas
| | - Wendy Gomez Garcia
- Oncology Unit, Dr Robert Reid Cabral Children’s Hospital, Santo Domingo, Dominican Republic
| | - Dylan E. Graetz
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Erica C. Kaye
- Division of Quality of Life and Palliative Care Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Monika L. Metzger
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | | | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Justin N. Baker
- Division of Quality of Life and Palliative Care Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
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18
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Agulnik A, Ferrara G, Puerto-Torres M, Gillipelli SR, Elish P, Muniz-Talavera H, Gonzalez-Ruiz A, Armenta M, Barra C, Diaz R, Hernandez C, Juárez Tobias S, de Jesus Loeza J, Mendez A, Montalvo E, Penafiel E, Pineda E, Graetz DE. Assessment of Barriers and Enablers to Implementation of a Pediatric Early Warning System in Resource-Limited Settings. JAMA Netw Open 2022; 5:e221547. [PMID: 35262714 PMCID: PMC8908074 DOI: 10.1001/jamanetworkopen.2022.1547] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Pediatric early warning systems (PEWS) aid with early identification of clinical deterioration and improve outcomes in children with cancer hospitalized in resource-limited settings; however, there may be barriers to implementation. OBJECTIVE To evaluate stakeholder-reported barriers and enablers to PEWS implementation in resource-limited hospitals. DESIGN, SETTING, AND PARTICIPANTS In this qualitative study, semistructured stakeholder interviews were conducted at 5 resource-limited pediatric oncology centers in 4 countries in Latin America. Hospitals participating in a multicenter collaborative to implement PEWS were purposefully sampled based on time required for implementation (fast vs slow), and stakeholders interviewed included physicians, nurses, and administrators, involved in PEWS implementation. An interview guide was developed using the Consolidated Framework for Implementation Research (CFIR). Interviews were conducted virtually in Spanish, audiorecorded, and professionally transcribed and translated into English. A codebook was developed a priori using the CFIR and supplemented with codes inductively derived from transcript review. Two coders independently analyzed all transcripts, achieving a κ of 0.8 to 0.9. The study was conducted from June 1 to August 31, 2020. MAIN OUTCOMES AND MEASURES Thematic analysis was conducted based on CFIR domains (inner setting, characteristics of individuals, outer setting, intervention characteristics, and implementation process) to identify barriers and enablers to PEWS implementation. RESULTS Seventy-one staff involved in PEWS implementation were interviewed, including 32 physicians (45%), 32 nurses (45%), and 7 administrators (10%). Of these, 50 were women (70%). Components of the 5 CFIR domains were mentioned by participants as barriers and enablers to PEWS implementation at both fast- and slow-implementing centers. Participants emphasized barriers at the level of the clinical staff, hospital, external factors, and PEWS intervention. These barriers included staff resistance to change, inadequate resources, components of health systems, and the perceived origin and complexity of PEWS. At all centers, most barriers were successfully converted to enablers during the implementation process through targeted strategies, such as early stakeholder engagement and adaptation, including adapting PEWS to better fit the local context and changing the hospital setting to support ongoing use of PEWS. CONCLUSIONS AND RELEVANCE To date, this is the first multicenter, multinational study describing barriers and enablers to PEWS implementation in resource-limited settings. Findings suggest that many barriers are not immutable and can be converted to enablers during the implementation process. This work can serve as a guide for clinicians looking to implement evidence-based interventions to reduce global disparities in patient outcomes.
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Affiliation(s)
- Asya Agulnik
- Department of Global Pediatric Medicine and Division of Critical Care, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Gia Ferrara
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Maria Puerto-Torres
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | | | - Paul Elish
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Hilmarie Muniz-Talavera
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Alejandra Gonzalez-Ruiz
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Miriam Armenta
- Department of Pediatric Oncology, Hospital General de Tijuana, Tijuana, México
| | - Camila Barra
- Department of Pediatric Oncology, Hospital Dr Luis Calvo Mackenna, Santiago, Chile
| | - Rosdali Diaz
- Instituto Nacional de Enfermedades Neoplásicas, Lima, Perú
| | - Cinthia Hernandez
- Department of Pediatric Oncology, Hospital Infantil Teletón de Oncología, Querétaro, México
| | | | - Jose de Jesus Loeza
- Department of Pediatric Oncology, Hospital Centro Estatal de Cancerología, Xalapa, México
| | - Alejandra Mendez
- Department of Pediatric Critical Care, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Erika Montalvo
- Department of Pediatric Critical Care, Hospital Oncológico Solca Núcleo de Quito, Quito, Ecuador
| | - Eulalia Penafiel
- Department of Pediatric Oncology, Instituto del Cáncer SOLCA Cuenca, Cuenca, Ecuador
| | - Estuardo Pineda
- Department of Pediatric Oncology, Hospital Nacional de Niños Benjamín Bloom, San Salvador, El Salvador
| | - Dylan E. Graetz
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
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19
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Graetz DE, Sniderman E, Villegas C, Ragab I, Laptsevich A, Maliti B, Naidu G, Zhang H, Gassant P, Nunes L, Arce D, Vasquez JM, Arora RS, Alcasabas AP, Rusmawatiningtyas D, Raza MR, Hamid SA, Velasco P, Kambugu J, Vinitsky A, Bolous NS, Haidar CE, Bihannic L, Sa da Bandeira D, Wang JX, Li D, Graca F, Vasilyeva A, Lesmana H, Galindo CR, Agulnik A, Moreira DC. Utilizing Multilingual Methods and Rapid Analysis for Global Qualitative Research During a Pandemic. Glob Qual Nurs Res 2022; 9:23333936221080969. [PMID: 35237707 PMCID: PMC8883294 DOI: 10.1177/23333936221080969] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Historically, qualitative research has complemented quantitative biologic and epidemiologic studies to provide a more complete understanding of pandemics. The COVID-19 pandemic has generated unique and novel challenges for qualitative researchers, who have embraced creative solutions including virtual focus groups and rapid analyses to continue their work. We present our experience conducting a multilingual global qualitative study of healthcare resilience among teams of pediatric oncology professionals during the COVID-19 pandemic. We provide an in-depth description of our methodology and an analysis of factors we believe contributed to our study’s success including our use of technology, engagement of a large multilingual team, global partnerships, and framework-based rapid analysis. We hope these techniques may be useful to qualitative researchers conducting studies during the current pandemic, as well as for all pediatric oncology studies including multiple languages or geographically disparate subjects.
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Affiliation(s)
| | | | | | - Iman Ragab
- Ain Shams University, Children’s Hospital, Hematology-Oncology Unit, Cairo, Egypt
| | - Aliaksandra Laptsevich
- Belarusian Research Center for Pediatric Oncology Hematology and Immunology, Minsk, Belarus
| | | | - Gita Naidu
- Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Hui Zhang
- Guangzhou Women and Children’s Medical Center, Guangzhou, China
| | | | | | - Daniela Arce
- Hospital Pediatrico de Sinaloa, Culiacan, Mexico
| | | | | | - Ana P Alcasabas
- University of the Philippines, Philippine General Hospital, Manila, Philippines
| | | | | | | | | | | | - Anna Vinitsky
- St Jude Children’s Research Hospital, Memphis, TN, USA
| | | | | | | | | | - Jade X Wang
- St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Dongfang Li
- St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Flavia Graca
- St Jude Children’s Research Hospital, Memphis, TN, USA
| | | | - Harry Lesmana
- St Jude Children’s Research Hospital, Memphis, TN, USA
| | | | - Asya Agulnik
- St Jude Children’s Research Hospital, Memphis, TN, USA
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20
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Graetz DE, Caceres-Serrano A, Radhakrishnan V, Salaverria CE, Kambugu JB, Sisk BA. A proposed global framework for pediatric cancer communication research. Cancer 2022; 128:1888-1893. [PMID: 35201609 PMCID: PMC9303244 DOI: 10.1002/cncr.34160] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/26/2022] [Accepted: 01/31/2022] [Indexed: 11/06/2022]
Abstract
The authors introduce a functional communication framework that can be used for global pediatric cancer research.
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Affiliation(s)
- Dylan E Graetz
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee.,Solid Tumor Division, Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Ana Caceres-Serrano
- Department of Psychology, Unidad Nacional Oncologia Pediatrica, Guatemala City, Guatemala
| | | | - Carmen E Salaverria
- Department of Psychology, Fundacion Ayudame a Vivir, San Salvador, El Salvador
| | - Joyce B Kambugu
- Department of Oncology, Uganda Cancer Institute, Kampala, Uganda
| | - Bryan A Sisk
- Division of Hematology and Oncology, Department of Pediatrics, Washington University, St. Louis, Missouri.,Bioethics Research Center, Department of Medicine, Washington University, St. Louis, Missouri
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21
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Ehrlich BS, Yakimkova T, Batmunkh T, Mishkova V, Movsisyan N, Kirgizov K, Borisevich M, Kizyma R, Graetz DE, McNeil MJ, Vinitsky A, Smelov V, Corbex M, Lam CG, Kaye EC, Baker JN, Agulnik A. Translating Research to Action: The Development of a Pediatric Palliative Cancer Care Advocacy Tool in Eurasia. JCO Glob Oncol 2022; 8:e2100270. [PMID: 35084997 PMCID: PMC8806380 DOI: 10.1200/go.21.00270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The Assessing Doctors' Attitudes on Palliative Treatment study was conducted in 11 Eurasian countries to assess physician knowledge of and structural barriers to integration of palliative care into pediatric oncology. After publication, regional collaborators identified the need to disseminate country-specific study results locally and provide policy recommendations to inform stakeholders. Translating research to action has never been more important in the field of global pediatric palliative oncology. ![]()
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Affiliation(s)
| | | | | | - Volha Mishkova
- Belarussian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Narine Movsisyan
- Anesthesiology and Intensive Care, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia
| | - Kirill Kirgizov
- N.N. Blokhin National Medical Research Center of Oncology, Moscow, Russia
| | - Marina Borisevich
- Belarussian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Roman Kizyma
- Western Ukrainian Specialized Children's Medical Centre, Lviv, Ukraine
| | | | | | | | - Vitaly Smelov
- World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Marilys Corbex
- World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | | | - Erica C Kaye
- St Jude Children's Research Hospital, Memphis, TN
| | | | - Asya Agulnik
- St Jude Children's Research Hospital, Memphis, TN
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22
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Sniderman ER, Graetz DE, Agulnik A, Ranadive R, Vedaraju Y, Chen Y, Devidas M, Chantada GL, Hessissen L, Dalvi R, Pritchard‐Jones K, Rodriguez‐Galindo C, Moreira DC, Bolous NS, Haidar CE, Bihannic L, Sa da Bandeira D, Wang JX, Li D, Graca F, Vasilyeva A, Lesmana H. Impact of the COVID‐19 pandemic on pediatric oncology providers globally: A mixed‐methods study. Cancer 2022; 128:1493-1502. [PMID: 35067925 PMCID: PMC9015299 DOI: 10.1002/cncr.34090] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/15/2021] [Accepted: 09/07/2021] [Indexed: 12/19/2022]
Abstract
Background Coronavirus disease 2019 (COVID‐19) disrupted pediatric oncology care globally, increasing demands on health care providers (HCPs) who adapted to continue care. This study sought to characterize the pandemic's impact on pediatric oncology HCPs worldwide. Methods A 60‐item survey focused on changes to clinical care, resources, and effects on clinicians. A diverse subgroup of institutions was purposefully selected for focus groups that explored teamwork, communication, and changes to care delivery. Results The survey included 311 responses from 213 institutions representing 79 countries. Sixteen institutions participated in 19 multidisciplinary focus groups in 8 languages. Decreased clinical staff availability was cited by 51% of institutions as a major impact. Staffing modifications included decreased provider availability (66% of institutions), roles or responsibility changes, and transfer outside the specialty. Physical effects included frequent COVID‐19 illness; 8% of respondents reported HCP deaths. Fifty percent of providers did not have the necessary personal protective equipment. HCPs also experienced psychological distress and financial concerns. Findings indicated more frequent impact on nurses than other providers. Impacts were described across all hospital resource levels, with staffing modifications more frequent in countries with higher COVID‐19 incidence (P < .001) and mortality rate (P = .004). Focus groups revealed negative impacts were stabilized by increased teamwork, communication, contributions outside usual roles, policies aimed at optimizing safety, and feeling that they were contributing. Conclusions COVID‐19 had a profound impact on the pediatric oncology workforce, creating challenging modifications to staffing and resulting in physical, psychological, and financial distress. Despite these challenges, HCPs caring for children with cancer came together to continue to provide high‐quality care. This mixed‐methods study reveals the impact that the coronavirus disease 2019 (COVID‐19) pandemic has had on pediatric oncology providers globally, and it highlights the importance of implementing strategies to protect the health care workforce during challenging situations.
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Affiliation(s)
- Elizabeth R. Sniderman
- Department of Global Pediatric Medicine St. Jude Children's Research Hospital Memphis Tennessee
| | - Dylan E. Graetz
- Department of Global Pediatric Medicine St. Jude Children's Research Hospital Memphis Tennessee
| | - Asya Agulnik
- Department of Global Pediatric Medicine St. Jude Children's Research Hospital Memphis Tennessee
| | - Radhikesh Ranadive
- Department of Global Pediatric Medicine St. Jude Children's Research Hospital Memphis Tennessee
| | - Yuvanesh Vedaraju
- Department of Global Pediatric Medicine St. Jude Children's Research Hospital Memphis Tennessee
| | - Yichen Chen
- Department of Global Pediatric Medicine St. Jude Children's Research Hospital Memphis Tennessee
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine St. Jude Children's Research Hospital Memphis Tennessee
| | - Guillermo L. Chantada
- Department of Pediatric Hematology and Oncology Fundacion Perez Scremini‐Hospital Pereira Rossell Montevideo Uruguay
- Department of Pediatric Hematology and Oncology Hospital Sant Joan de Deu Barcelona Spain
| | - Laila Hessissen
- Department of Pediatric Hematology and Oncology Mohammed V University Rabat Morocco
| | - Rashmi Dalvi
- Department of Pediatrics Bombay Hospital Institute of Medical Sciences Bombay India
| | - Kathy Pritchard‐Jones
- Great Ormond Street Institute of Child Health University College London London England
| | | | - Daniel C. Moreira
- Department of Global Pediatric Medicine St. Jude Children's Research Hospital Memphis Tennessee
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23
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Agulnik A, Schmidt-Grimminger G, Ferrara G, Puerto-Torres M, Gillipelli SR, Elish P, Muniz-Talavera H, Gonzalez-Ruiz A, Armenta M, Barra C, Diaz-Coronado R, Hernandez C, Juarez S, Loeza JDJ, Mendez A, Montalvo E, Penafiel E, Pineda E, Graetz DE, McKay V. Challenges to sustainability of pediatric early warning systems (PEWS) in low-resource hospitals in Latin America. Front Health Serv 2022; 2:1004805. [PMID: 36925775 PMCID: PMC10012640 DOI: 10.3389/frhs.2022.1004805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 10/10/2022] [Indexed: 11/29/2022]
Abstract
Background Sustainability, or continued use of evidence-based interventions for long-term patient benefit, is the least studied aspect of implementation science. In this study, we evaluate sustainability of a Pediatric Early Warning System (PEWS), an evidence-based intervention to improve early identification of clinical deterioration in hospitalized children, in low-resource settings using the Clinical Capacity for Sustainability Framework (CCS). Methods We conducted a secondary analysis of a qualitative study to identify barriers and enablers to PEWS implementation. Semi-structured interviews with PEWS implementation leaders and hospital directors at 5 Latin American pediatric oncology centers sustaining PEWS were conducted virtually in Spanish from June to August 2020. Interviews were recorded, professionally transcribed, and translated into English. Exploratory thematic content analysis yielded staff perceptions on PEWS sustainability. Coded segments were analyzed to identify participant perception about the current state and importance of sustaining PEWS, as well as sustainability successes and challenges. Identified sustainability determinants were mapped to the CCS to evaluate its applicability. Results We interviewed 71 staff including physicians (45%), nurses (45%), and administrators (10%). Participants emphasized the importance of sustaining PEWS for continued patient benefits. Identified sustainability determinants included supportive leadership encouraging ongoing interest in PEWS, beneficial patient outcomes enhancing perceived value of PEWS, integrating PEWS into the routine of patient care, ongoing staff turnover creating training challenges, adequate material resources to promote PEWS use, and the COVID-19 pandemic. While most identified factors mapped to the CCS, COVID-19 emerged as an additional external sustainability challenge. Together, these challenges resulted in multiple impacts on PEWS sustainment, ranging from a small reduction in PEWS quality to complete disruption of PEWS use and subsequent loss of benefits to patients. Participants described several innovative strategies to address identified challenges and promote PEWS sustainability. Conclusion This study describes clinician perspectives on sustainable implementation of evidence-based interventions in low-resource settings, including sustainability determinants and potential sustainability strategies. Identified factors mapped well to the CCS, however, external factors, such as the COVID pandemic, may additionally impact sustainability. This work highlights an urgent need for theoretically-driven, empirically-informed strategies to support sustainable implementation of evidence-based interventions in settings of all resource-levels.
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Affiliation(s)
- Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | | | - Gia Ferrara
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Maria Puerto-Torres
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | | | - Paul Elish
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Hilmarie Muniz-Talavera
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Alejandra Gonzalez-Ruiz
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Miriam Armenta
- Pediatric Oncology, Hospital General de Tijuana, Tijuana, Mexico
| | - Camila Barra
- Pediatric Oncology, Hospital Dr. Luis Calvo Mackenna, Santiago, Chile
| | | | - Cinthia Hernandez
- Pediatric Oncology, Hospital Infantil Teletón de Oncología, Querétaro, Mexico
| | - Susana Juarez
- Pediatrics, Hospital Central Dr. Ignacio Morones Prieto, San Luis Potosí, Mexico
| | | | - Alejandra Mendez
- Pediatric Critical Care, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Erika Montalvo
- Pediatric Critical Care, Hospital Oncológico Solca Núcleo de Quito, Quito, Ecuador
| | - Eulalia Penafiel
- Pediatric Oncology, Instituto del Cáncer SOLCA Cuenca, Cuenca, Ecuador
| | - Estuardo Pineda
- Pediatric Oncology, Hospital Nacional de Niños Benjamín Bloom, San Salvador, El Salvador
| | - Dylan E Graetz
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Virginia McKay
- Brown School, Washington University, St. Louis, MO, United States
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24
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Graetz DE, Sniderman E, Villegas CA, Kaye EC, Ragab I, Laptsevich A, Maliti B, Naidu G, Huang H, Gassant PY, Nunes Silva L, Arce D, Montoya Vasquez J, Arora RS, Alcasabas AP, Rusmawatiningtyas D, Raza MR, Velasco P, Kambugu J, Vinitsky A, Rodriguez-Galindo C, Agulnik A, Moreira DC. Resilient health care in global pediatric oncology during the COVID-19 pandemic. Cancer 2021; 128:797-807. [PMID: 34767629 PMCID: PMC8653316 DOI: 10.1002/cncr.34007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 05/24/2021] [Accepted: 06/10/2021] [Indexed: 12/23/2022]
Abstract
Background In the face of unprecedented challenges because of coronavirus disease 2019, interdisciplinary pediatric oncology teams have developed strategies to continue providing high‐quality cancer care. This study explored factors contributing to health care resilience as perceived by childhood cancer providers in all resource level settings. Methods This qualitative study consisted of 19 focus groups conducted in 16 countries in 8 languages. Seven factors have been previously defined as important for resilient health care including: 1) in situ practical experience, 2) system design, 3) exposure to diverse views on the patient's situation, 4) protocols and checklists, 5) teamwork, 6) workarounds, and 7) trade‐offs. Rapid turn‐around analysis focused on these factors. Results All factors of health care resilience were relevant to groups representing all resource settings. Focus group participants emphasized the importance of teamwork and a flexible and coordinated approach to care. Participants described collaboration within and among institutions, as well as partnerships with governmental, private, and nonprofit organizations. Hierarchies were advantageous to decision‐making and information dissemination. Clinicians were inspired by their patients and explained creative trade‐offs and workarounds used to maintain high‐quality care. Conclusions Factors previously described as contributing to resilient health care manifested differently in each institution but were described in all resource settings. These insights can guide pediatric oncology teams worldwide as they provide cancer care during the next phases of the pandemic. Understanding these elements of resilience will also help providers respond to inevitable future stressors on health care systems. This multinational, multicenter, qualitative study illustrates how pediatric oncology providers used resilient health care strategies, illuminating creative solutions to mitigate impact, many of which may outlast the pandemic.
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Affiliation(s)
- Dylan E Graetz
- St. Jude Children's Research Hospital, Memphis, Tennessee
| | | | | | - Erica C Kaye
- St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Iman Ragab
- Hematology-Oncology Unit, Ain Shams University, Children's Hospital, Cairo, Egypt
| | - Aliaksandra Laptsevich
- Belarusian Research Center for Pediatric Oncology Hematology and Immunology, Minsk, Belarus
| | | | - Gita Naidu
- Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Haiying Huang
- Guangzhou Women and Children's Medical Center, Guangzhou, China
| | | | | | - Daniela Arce
- Hospital Pediatrico de Sinaloa, Culiacan, Mexico
| | | | | | | | | | | | - Pablo Velasco
- Pediatric Oncology and Hematology Department, Vall d'Hebron Hospital, Barcelona, Spain
| | | | - Anna Vinitsky
- St. Jude Children's Research Hospital, Memphis, Tennessee
| | | | - Asya Agulnik
- St. Jude Children's Research Hospital, Memphis, Tennessee
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25
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Graetz DE, Rivas SE, Wang H, Vedaraju Y, Fuentes AL, Caceres-Serrano A, Antillon-Klussmann F, Devidas M, Metzger ML, Rodriguez-Galindo C, Mack JW. Communication Priorities and Experiences of Caregivers of Children With Cancer in Guatemala. JCO Glob Oncol 2021; 7:1529-1536. [PMID: 34748391 PMCID: PMC8577673 DOI: 10.1200/go.21.00232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Although > 90% of children with cancer live in low- and middle-income countries, little is known about communication priorities and experiences of families in these settings. We examined communication priorities and the quality of information exchange for Guatemalan caregivers of children with cancer during diagnostic communication. METHODS A cross-sectional survey including items used in pediatric communication studies from high-income countries and novel questions was verbally administered to 100 caregivers of children with cancer in Guatemala. RESULTS Guatemalan caregivers prioritized communication functions of exchanging information (99%), fostering healing relationships (98%), decision making (97%), enabling self-management (96%), and managing uncertainty (94%) over responding to emotions (66%) and cultural awareness (48%). Almost all caregivers wanted as many details as possible about their child's diagnosis and treatment (96%), likelihood of cure (99%), and late effects (97%). Only 67% were always given the information they needed without asking for it, and most caregivers sometimes (56%) or always (18%) had questions they wanted to discuss but did not. Approximately half of the caregivers (54%) correctly identified their child's diagnosis, primary site, disease extent (localized v metastatic), proposed treatment length, and treatment intent (curative v palliative). Caregivers of children with leukemia were more likely to correctly identify all attributes than those whose children had solid tumors (P < .001). CONCLUSION Caregivers in Guatemala prioritize many of the same aspects of diagnostic communication as parents in the United States, and experience similar challenges. Shared communication values offer potential for adaptation of communication interventions across settings with varying resources and diverse cultures. Communication priorities and experiences of caregivers of children with cancer in Guatemala similar to those in US.![]()
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Affiliation(s)
| | | | - Huiqi Wang
- St Jude Children's Research Hospital, Memphis, TN
| | | | | | | | - Federico Antillon-Klussmann
- Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala.,Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | | | | | | | - Jennifer W Mack
- Dana Farber Cancer Institute/Boston Children's Hospital, Boston, MA
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26
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Garza M, Graetz DE, Kaye EC, Ferrara G, Rodriguez M, Soberanis Vásquez DJ, Méndez Aceituno A, Antillon-Klussmann F, Gattuso JS, Mandrell BN, Baker JN, Rodriguez-Galindo C, Agulnik A. Impact of PEWS on Perceived Quality of Care During Deterioration in Children With Cancer Hospitalized in Different Resource-Settings. Front Oncol 2021; 11:660051. [PMID: 34249696 PMCID: PMC8260684 DOI: 10.3389/fonc.2021.660051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/31/2021] [Indexed: 12/16/2022] Open
Abstract
Background Children with cancer are at high risk for clinical deterioration and subsequent mortality. Pediatric Early Warning Systems (PEWS) have proven to reduce the frequency of clinical deterioration in hospitalized patients. This qualitative study evaluates provider perspectives on the impact of PEWS on quality of care during deterioration events in a high-resource and a resource-limited setting. Methods We conducted semi-structured interviews with 83 healthcare staff (nurses, pediatricians, oncology fellows, and intensivists) involved in recent deterioration events at two pediatric oncology hospitals of different resource levels: St. Jude Children’s Research Hospital (SJCRH; n = 42) and Unidad Nacional de Oncología Pediátrica (UNOP; n = 41). Interviews were conducted in the participant’s native language (English or Spanish), translated into English, and transcribed. Transcripts were coded and analyzed inductively. Results Providers discussed both positive and negative perspectives of clinical deterioration events. Content analysis revealed “teamwork,” “experience with deterioration,” “early awareness,” and “effective communication” as themes associated with positive perception of events, which contributed to patient safety. Negative themes included “lack of communication,” “inexperience with deterioration,” “challenges with technology”, “limited material resources,” “false positive score,” and “objective tool.” Participants representing all disciplines across both institutions shared similar positive opinions. Negative opinions, however, differed between the two institutions, with providers at UNOP highlighting limited resources while those at SJCRH expressing concerns about technology misuse. Conclusion Providers that care for children with cancer find PEWS valuable to improve the quality of hospital care, regardless of hospital resource-level. Identified challenges, including inadequate critical care resources and challenges with technology, differ by hospital resource-level. These findings build on growing data demonstrating the positive impact of PEWS on quality of care and encourage wide dissemination of PEWS in clinical practice.
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Affiliation(s)
- Marcela Garza
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Dylan E Graetz
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Erica C Kaye
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Gia Ferrara
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Mario Rodriguez
- Department of Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | | | | | - Federico Antillon-Klussmann
- Department of Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala.,Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | - Jami S Gattuso
- Department of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Belinda N Mandrell
- Department of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Justin N Baker
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States.,Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, United States
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McNeil M, Ehrlich B, Bustamante M, Dussel V, Friedrich P, Garcia Quintero X, Gomez Garcia WC, Graetz DE, Kaye E, Metzger M, Sabato Danon CV, Baker JN, Agulnik A. Assessment of physician perceptions of pediatric palliative care for children with cancer in Latin America. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.10053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10053 Background: While great strides have transpired in pediatric cancer management in high-income countries (HICs), more than 80% of all children with cancer live in low-and middle-income countries (LMICs),where fewer than 20% will be cured. The World Health Organization (WHO) has stated that early integration of palliative care is an ethical responsibility in the management of children with life-limiting illness. While structural barriers impact the ability to deliver pediatric palliative care (PPC), underlying stigma also prevents early integration of PPC. Methods: The Assessing Doctor’s Attitudes on Palliative Treatment (ADAPT) survey was created for physicians of all specialties who care for children with cancer, initially used in Eurasia. Survey questions evaluated provider perceptions on timing of palliative care integration, scope of palliative treatment, physician responsibility, and ethical issues. This survey was adapted for use in Latin America, including translation to Spanish and reviewed by regional palliative care specialists for syntax, comprehension, and cultural relevance. The survey was then distributed to physicians treating children with cancer in the region. To assess provider’s perspectives on palliative care, we used fifteen statements from the WHO 2018 guidelines, describing general palliative care principles. Results are reported as percent of alignment with guidelines. Results: A total of 1,039 participants from 16 countries in Latin America completed the survey, with a median country response rate of 66% (range 26%-100%). Thirty-six specialties were represented with 34% general pediatricians and 23% pediatric hematologist/oncologists. The majority (59%) had received no PPC training and 37% had no access to PPC experts for consultation in their practice setting. On average, provider’s perspectives on PPC were aligned with the WHO guidelines (81% alignment, range 53%-96%). However, almost half (42%) felt that the integration of pediatric palliative occurred too late in the course of treatment. Additionally, less than half (47%) of respondents felt comfortable addressing the physical symptoms of their patients, 33% felt comfortable addressing emotional symptoms, and only 26% felt comfortable addressing grief and bereavement for the patient’s family. The most common barriers identified were a lack of home-based services (87%), a lack of physician knowledge on the role of PPC (84%), and physician discomfort in discussing palliative care with families (81%). Nearly all (95%) wanted more training in PPC. Conclusions: Most physicians who completed the survey were not confident in providing symptomatic and supportive care for their patients and families. This study will guide targeted interventions for education in PPC for physicians in Latin America as well as interventions to address barriers which impede earlier palliative care integration in the region.
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Affiliation(s)
| | | | | | - Veronica Dussel
- Center for Research and Implementation in Palliative Care, Buenos Aires, Argentina
| | | | | | | | | | - Erica Kaye
- St. Jude Children's Research Hospital, Memphis, TN
| | | | | | | | - Asya Agulnik
- St. Jude Children's Research Hospital, Memphis, TN
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28
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Graetz DE, Rivas SE, Wang H, Vedaraju Y, Devidas M, Fuentes AL, Caceres-Serrano A, Antillon-Klussmann F, Metzger M, Rodriguez-Galindo C, Mack JW. Pediatric cancer communication in Guatemala. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e18508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18508 Background: Effective diagnostic communication is a cornerstone of cancer care. While > 90% of children with cancer live in low- and middle-income countries, little is known about patients’ and families’ communication priorities and experiences. We examined parent priorities for communication and the quality of information-exchange and decision-making during diagnostic communication in Guatemala. Methods: This study was conducted at Unidad Nacional de Oncologia Pediatrica. A cross-sectional survey was verbally administered in Spanish to 100 parents of children with cancer within 8 weeks of diagnosis. The survey included items utilized in pediatric communication studies from high-income countries and novel questions developed specifically for the study population. Results: Guatemalan parents prioritized communication functions including information exchange (99%), fostering healing relationships (98%), decision-making (97%), enabling self-management (96%) and managing uncertainty (94%) over functions such as responding to emotions (66%) and cultural awareness (48%). Almost all Guatemalan parents (96%) wanted as many details as possible about their child’s cancer. However, only 67% reported that they were always given the information they needed without asking for it, and most said they sometimes (56%) or always (18%) had questions they wanted to discuss with the doctor but did not. Half of parents (54%) correctly identified their child’s diagnosis, primary site, extent of disease (localized versus metastatic), length of proposed treatment, and treatment intent (curative versus palliative). Parents of children diagnosed with leukemia were more likely to understand all pieces of information than those whose children had solid tumors (p < 0.001). Most parents (76%) preferred to share in decision-making with oncologists. Two-thirds of parents (65%) held their preferred role in decision-making, with fathers more likely to hold their preferred role than mothers (p = 0.02). Reflecting on decisions they had made, 94% of parents strongly agreed they had made the right decisions. However, 17% of parents endorsed feeling that their choices had caused their children harm. Conclusions: Similar to findings from the United States, parents in Guatemala prioritize many aspects of diagnostic communication, especially information exchange, development of healing relationships, and decision-making. Nonetheless, many parents report challenges in information exchange and decision-making, suggesting a need for interventions to support communication processes.
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Affiliation(s)
| | | | - Huiqi Wang
- St. Jude Children's Research Hospital, Memphis, TN
| | | | | | | | | | | | | | | | - Jennifer W. Mack
- Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center, Boston, MA
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29
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Graetz DE, Giannars E, Kaye EC, Garza M, Ferrara G, Rodriguez M, Soberanis Vasquez DJ, Mendez Aceituno A, Antillon-Klussmann F, Gattuso JS, Andes KL, Mandrell BN, Baker JN, Rodriguez-Galindo C, Agulnik A. Clinician Emotions Surrounding Pediatric Oncology Patient Deterioration. Front Oncol 2021; 11:626457. [PMID: 33718195 PMCID: PMC7947818 DOI: 10.3389/fonc.2021.626457] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/18/2021] [Indexed: 12/16/2022] Open
Abstract
Background Pediatric oncology patients have a high rate of clinical deterioration frequently requiring critical care. Patient deterioration events are distressing for clinicians, but little is known about how Pediatric Early Warning Systems (PEWS) impact clinicians' emotional responses to deterioration events. Methods Semi-structured interviews were conducted with 83 nurses, pediatricians, oncologists, and intensive care clinicians who had recently participated in a patient deterioration event at two pediatric oncology hospitals of different resource-levels: St. Jude Children's Research Hospital (N = 42 participants) in Memphis, Tennessee or Unidad Nacional de Oncología Pediátrica (N = 41 participants) in Guatemala City, Guatemala. Interviews were conducted in the participants' native language (English or Spanish), transcribed, and translated into English. Each transcript was coded by two researchers and analyzed for thematic content. Results Emotions around patient deterioration including concern, fear, and frustration were reported across all disciplines at both hospitals. Concern was often triggered by an elevated PEWS score and usually resulted in increased attention, which reassured bedside clinicians that patients were receiving necessary interventions. However, persistently elevated PEWS scores, particularly at St. Jude Children's Research Hospital, occasionally resulted in a false sense of relief, diminishing clinician attention and negatively impacting patient care. Nurses at both institutions described how PEWS amplified their voices, engendering confidence and empowerment, two of the only positive emotions described in the study. Conclusion Clinicians experienced a range of emotions while caring for high-risk patients in the setting of clinical deterioration. These emotions have the potential to contribute to compassion fatigue and burnout, or to resilience. Acknowledgment and further investigation of the complex interplay between PEWS and clinician emotions are necessary to maximize the impact of PEWS on patient safety while simultaneously supporting staff wellbeing.
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Affiliation(s)
- Dylan E Graetz
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Emily Giannars
- Department of Public Health, Emory University School of Public Health, Atlanta, GA, United States
| | - Erica C Kaye
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Marcela Garza
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Gia Ferrara
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Mario Rodriguez
- Department of Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | | | | | - Federico Antillon-Klussmann
- Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala.,Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | - Jami S Gattuso
- Department of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Karen L Andes
- Department of Public Health, Emory University School of Public Health, Atlanta, GA, United States
| | - Belinda N Mandrell
- Department of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Justin N Baker
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
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30
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Graetz DE, Garza M, Rodriguez-Galindo C, Mack JW. Pediatric cancer communication in low- and middle-income countries: A scoping review. Cancer 2020; 126:5030-5039. [PMID: 32991761 DOI: 10.1002/cncr.33222] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/30/2020] [Accepted: 09/01/2020] [Indexed: 01/20/2023]
Abstract
The burden of global childhood cancer lies in low- and middle-income countries (LMICs). Communication is essential to pediatric cancer care, and the National Cancer Institute (NCI) has defined 6 functions of communication between patients, family members, and providers, including 1) fostering healing relationships, 2) responding to emotions, 3) exchanging information, 4) making decisions, 5) managing uncertainty, and 6) enabling self-management. Nevertheless, communication needs and practices in LMICs remain incompletely understood. For this review, the Web of Science, Scopus, PubMed, and Turning Research Into Practice databases were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews. Searching identified 2988 articles, with 11 added through snowballing. Forty articles met the inclusion criteria. Two reviewers extracted data on study characteristics, communication functions, enablers, barriers, and additional major themes. This review included work from 17 countries. Most studies (85%) used qualitative methodology; the number of participants ranged from 7 to 304. All 6 of the NCI-defined communication functions were identified in included studies, with rates ranging from 100% of studies for information exchange to 28% of studies for decision making. Communication barriers included cancer misconceptions, stigma, and hierarchy between parents and providers. Provider training and community education facilitated communication. Additional themes included disclosure to children, family dynamics, and the multidisciplinary health care team. In conclusion, all 6 of the communication functions defined by the NCI were applied by pediatric cancer researchers in LMICs. Additional barriers, enablers, and communication themes noted in LMICs deserve further exploration, and a relative paucity of research in comparison with high-income countries highlights the need for further work.
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Affiliation(s)
- Dylan E Graetz
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Marcela Garza
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Carlos Rodriguez-Galindo
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Jennifer W Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Hospital, Boston, Massachusetts.,Division of Population Sciences, Dana-Farber Cancer Institute/Boston Children's Hospital, Boston, Massachusetts
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31
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Graetz DE, Chen Y, Devidas M, Antillon-Klussmann F, Fu L, Quintero K, Fuentes-Alabi SL, Gassant PY, Kaye EC, Baker JN, Rodriguez Galindo C, Mack JW. Interdisciplinary care of pediatric oncology patients in Central America and the Caribbean. Cancer 2020; 127:2579-2586. [PMID: 33237591 DOI: 10.1002/cncr.33339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/12/2020] [Accepted: 10/27/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Interdisciplinary teamwork supports high-quality cancer care and effective utilization of limited resources. This study purposed to examine the value, structure, process, and effectiveness of interdisciplinary care (IDC) among pediatric oncology providers in low-income and middle-income countries in Central America and the Caribbean. METHODS A cross-sectional survey was disseminated to pediatric oncology providers at 5 centers participating in the Pediatric Hematology-Oncology Association of Central America. The survey included previously validated items and novel questions assessing the value (importance), structure (multidisciplinary meeting attendance), process (team climate), and effectiveness (job satisfaction, quality of care and communication) of IDC. RESULTS The survey was completed by 174 providers, including 22 oncologists, 9 pathologists, 9 radiologists, 5 radiation oncologists, 12 surgeons, 35 subspecialists, 60 nurses, 20 psychosocial providers, and 2 other staff. Participants agreed that IDC benefits team members (95%) and patients (96%). IDC structure and processes varied across the region. Multidisciplinary meeting attendance differed by center (P = .005) and discipline (P < .0001). Participants who frequently attended multidisciplinary meetings reported a more positive team climate (P = .0003). Team climate was positively associated with job satisfaction (P < .001). In multivariable analyses, team climate was predictive of an improved perception of communication between professionals (P < .0001), with families (P < .0001), and with patients (P = .0005), as well as with quality of the care environment (P = .006) and overall care quality (P < .0001). CONCLUSIONS Nearly all surveyed participants valued IDC, and the structure and processes supporting IDC varied by center. Associations between a collaborative professional climate, job satisfaction, and the perception of quality care encourage continued investigation and prioritization of IDC in these settings.
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Affiliation(s)
- Dylan E Graetz
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee.,Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Yichen Chen
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Federico Antillon-Klussmann
- National Unit of Pediatric Oncology, Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | - Ligia Fu
- Pediatric Hematology and Oncology Unit, Tegucigalpa School Hospital, Tegucigalpa, Honduras
| | - Karina Quintero
- Pediatric Oncology Unit, Dr Jose Renan Esquivel Children's Hospital, Panama City, Panama
| | - Soad L Fuentes-Alabi
- Department of Oncology, Benjamin Bloom National Children's Hospital, El Salvador City, El Salvador
| | | | - Erica C Kaye
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee.,Division of Palliative and End of Life Care, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Justin N Baker
- Division of Palliative and End of Life Care, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Carlos Rodriguez Galindo
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Jennifer W Mack
- Pediatric Oncology/Oncology, Dana Farber Cancer Institute and Boston Children's Hospital, Boston, Massachusetts
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32
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Graetz DE, Madni A, Gossett J, Kang G, Sabin JA, Santana VM, Russo CL. Role of implicit bias in pediatric cancer clinical trials and enrollment recommendations among pediatric oncology providers. Cancer 2020; 127:284-290. [PMID: 33119199 PMCID: PMC7790838 DOI: 10.1002/cncr.33268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Provider implicit bias can negatively affect clinician-patient communication. In the current study, the authors measured implicit bias training among pediatric oncology providers and exposure to implicit association tests (IATs). They then assessed associations between IATs for race and socioeconomic status (SES) and recommendations for clinical trial enrollment. METHODS A prospective multisite study was performed to measure implicit bias among oncology providers at St. Jude Children's Research Hospital and affiliate clinics. An IAT was used to assess bias in the domains of race and SES. Case vignettes were used to determine an association between bias and provider recommendation for trial enrollment. Data were analyzed using Student t tests or Wilcoxon tests for comparisons and Jonckheere-Terpstra tests were used for association. RESULTS Of the 105 total participants, 95 (90%) had not taken an IAT and 97 (92%) had no prior implicit bias training. A large effect was found for (bias toward) high SES (Cohen d, 1.93) and European American race (Cohen d, 0.96). The majority of participants (90%) had a vignette score of 3 or 4, indicating recommendation for trial enrollment for most or all vignettes. IAT and vignette scores did not significantly differ between providers at St. Jude Children's Research Hospital or affiliate clinics. No association was found between IAT and vignette scores for race (P = .58) or SES (P = .82). CONCLUSIONS The authors noted a paucity of prior exposure to implicit bias self-assessments and training. Although these providers demonstrated preferences for high SES and European American race, this did not appear to affect recommendations for clinical trial enrollment as assessed by vignettes.
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Affiliation(s)
- Dylan E Graetz
- Department of Oncology, St. Jude Children's Research Hospital and Comprehensive Cancer Center, Memphis, Tennessee
| | - Arshia Madni
- Department of Oncology, St. Jude Children's Research Hospital and Comprehensive Cancer Center, Memphis, Tennessee
| | - Jeffrey Gossett
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Guolian Kang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Janice A Sabin
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington
| | - Victor M Santana
- Department of Oncology, St. Jude Children's Research Hospital and Comprehensive Cancer Center, Memphis, Tennessee
| | - Carolyn L Russo
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee
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33
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Ehrlich BS, Movsisyan N, Batmunkh T, Kumirova E, Borisevich MV, Kirgizov K, Graetz DE, McNeil MJ, Yakimkova T, Vinitsky A, Ferrara G, Li C, Lu Z, Kaye EC, Baker JN, Agulnik A. Barriers to the early integration of palliative care in pediatric oncology in 11 Eurasian countries. Cancer 2020; 126:4984-4993. [PMID: 32813913 DOI: 10.1002/cncr.33151] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/03/2020] [Accepted: 07/13/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND The early integration of palliative care significantly improves quality of life for children with cancer. However, cultural, structural, and socioeconomic barriers can delay the integration of palliative care into cancer care, particularly in low-income and middle-income countries. To date, little is known regarding the timing of and barriers to palliative care integration in Eurasia. METHODS The Assessing Doctors' Attitudes on Palliative Treatment (ADAPT) survey evaluates physician perceptions regarding palliative care integration into pediatric oncology in Eurasia. This evidence-based survey was adapted to the regional context; iteratively reviewed by US and regional panelists; and piloted in English, Russian, and Mongolian. After distribution to physicians caring for children with cancer, statistical analysis was complemented by qualitative analysis of open-ended responses. RESULTS A total of 424 physician responses were received from 11 countries in the Eurasian region. Study findings demonstrated wide variability in access to palliative care experts across countries (18%-96%), with the majority of providers (64%) reporting that the initial palliative care consultation typically occurs when curative options are no longer available. Providers desired an earlier initial palliative care consultation than what currently occurs in their setting (P < .001). Primary barriers to timely consultation included limited access to palliative care services and specialists, lack of physician education, and perceived family resistance. CONCLUSIONS The current study is the first to identify physician perceptions of the delayed timing of palliative care integration into childhood cancer care and associated barriers in Eurasia. These findings will inform the development of targeted interventions to mitigate local structural and cultural barriers to access and facilitate earlier palliative care integration in the region.
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Affiliation(s)
- Bella S Ehrlich
- Warren Alpert Medical School, Brown University, Providence, Rhode Island.,Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Narine Movsisyan
- Yerevan State Medical University after Mkhitar Heratsi, Yerevan, Armenia
| | | | - Ella Kumirova
- Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Marina V Borisevich
- Belarusian Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | | | - Dylan E Graetz
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Michael J McNeil
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Taisiya Yakimkova
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Anna Vinitsky
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Gia Ferrara
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Chen Li
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Zhaohua Lu
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Erica C Kaye
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Justin N Baker
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
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Ehrlich BS, Movsisyan N, Batmunkh T, Kumirova E, Borisevich MV, Kirgizov K, Graetz DE, McNeil MJ, Yakimkova T, Vinitsky A, Ferrara G, Li C, Lu Z, Kaye EC, Baker JN, Agulnik A. A multicountry assessment in Eurasia: Alignment of physician perspectives on palliative care integration in pediatric oncology with World Health Organization guidelines. Cancer 2020; 126:3777-3787. [PMID: 32530519 DOI: 10.1002/cncr.33001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 04/10/2020] [Accepted: 05/13/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND The World Health Organization (WHO) advocates for early integration of palliative care for all children with life-threatening illness. Provider awareness and misperceptions, however, can impede this imperative. In the Eurasian region, little is known about physician knowledge and perspectives on palliative care. METHODS The Assessing Doctors' Attitudes on Palliative Treatment survey was developed as an evidence-based and culturally relevant assessment of physician perceptions on palliative care integration into childhood cancer care in Eurasia. Iteratively tested by American and Eurasian palliative care experts, the survey was culturally adapted, translated, and piloted in English, Russian, and Mongolian. The survey was distributed to physicians caring for children with cancer. Fifteen statements were scored in accordance with WHO guidelines to evaluate provider knowledge. The statistical analysis was complemented by a qualitative analysis of open-ended responses. RESULTS This study received 424 responses from 11 countries in Eurasia. The mean alignment between provider perspectives and WHO recommendations was 70% (range, 7%-100%). Significant independent predictors of higher alignment included country, prior palliative care education, and greater experience with patient death. Respondents primarily described palliative care as end-of-life care and symptom management. Two-thirds of respondents (67%) reported not feeling confident about delivering at least 1 component of palliative care. CONCLUSIONS This is the first study assessing physician perspectives and knowledge of palliative care in Eurasia and reveals wide variability in alignment with WHO guidelines and limited confidence in providing palliative care. Study findings will inform targeted educational interventions, which must be tailored to the local political, economic, and cultural context.
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Affiliation(s)
- Bella S Ehrlich
- Brown University, Providence, Rhode Island.,Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Narine Movsisyan
- Yerevan State Medical University After Mkhitar Heratsi, Yerevan, Armenia
| | | | - Ella Kumirova
- Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology, and Immunology, Moscow, Russia
| | - Marina V Borisevich
- Belarusian Center for Pediatric Oncology, Hematology, and Immunology, Minsk, Belarus
| | - Kirill Kirgizov
- N. N. Blokhin Russian Cancer Research Center, Moscow, Russia
| | - Dylan E Graetz
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Michael J McNeil
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Taisiya Yakimkova
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Anna Vinitsky
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Gia Ferrara
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Chen Li
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Zhaohua Lu
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Erica C Kaye
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Justin N Baker
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
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35
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Graetz DE. Finding Grace in Grief. J Clin Oncol 2020; 38:645-646. [PMID: 31675253 DOI: 10.1200/jco.19.02123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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