Understanding facilitators and barriers to contraception screening and referral in young women with cancer

BACKGROUND: Young women with cancer often worry about impaired fertility after treatment but can experience devastating consequences from an unplanned pregnancy during treatment. Contraception screening and referral appear to occur infrequently in cancer care. OBJECTIVES: We sought to understand oncologic providers’ current practices, perceptions of facilitators and barriers to screening for adequate contraception during cancer treatment, and to understand patient perspectives on these processes. METHODS: We interviewed 19 oncologic providers and 20 female reproductive-aged oncology patients stable on treatment or who had completed therapy within the last 24 months. We recruited participants from an urban, northeast medical center where they worked or received oncologic care. Semi-structured interview questions examined components of the Promoting Action on Research Implementation in Health Services (PARiHS) framework, and subsequent constant comparative analysis identified similar themes. FINDINGS: Providers vary significantly in their current contraception screening practices with many focusing on diagnosing pregnancy rather than prevention. Providers identified many institutional and organizational barriers, including lack of education and lack of clear provider responsibility. Providers also identified resources and supports that would assist with contraception screening and referral, including education and enhanced interdisciplinary collaboration with gynecologic providers. Patients infrequently recalled contraception conversations with oncology providers and expressed challenges determining the most appropriate provider with whom to discuss contraception. CONCLUSION: Cancer centers should address barriers to contraception screening and referral locally in future implementation of contraception screening and referral. National organizations should work to develop guidelines to inform and support this process in clinical practice.2019-10-23T00:00:00

Towards equity and equality in healthcare:Accelerating the implementation of shared decision-making in routine (oncology) practice

This thesis presents implementation research in the field of shared decision-making: what barriers and facilitating factors play a role in hindering or accelerating adoption? Approaches to implementation are evaluated: these focus on organisational and socio-political aspects, on the use of tools and theory regarding shared decision-making and on how to influence the behaviour of healthcare clinicians

Towards equity and equality in healthcare:Accelerating the implementation of shared decision-making in routine (oncology) practice

This thesis presents implementation research in the field of shared decision-making: what barriers and facilitating factors play a role in hindering or accelerating adoption? Approaches to implementation are evaluated: these focus on organisational and socio-political aspects, on the use of tools and theory regarding shared decision-making and on how to influence the behaviour of healthcare clinicians

Study protocol: a cluster randomized controlled trial of web-based decision support tools for increasing BRCA1/2 genetic counseling referral in primary care

Background BRCA1 and BRCA2 mutations confer a substantial breast risk of developing breast cancer to those who carry them. For this reason, the United States Preventative Services Task Force (USPSTF) has recommended that all women be screened in the primary care setting for a family history indicative of a mutation, and women with strong family histories of breast or ovarian cancer be referred to genetic counseling. However, few high-risk women are being routinely screened and fewer are referred to genetic counseling. To address this need we have developed two decision support tools that are integrated into clinical care. Method This study is a cluster randomized controlled trial of high-risk patients and their health care providers. Patient-provider dyads will be randomized to receive either standard education that is supplemented with the patient-facing decision aid, RealRisks, and the provider-facing Breast Cancer Risk Navigation Toolbox (BNAV) or standard education alone. We will assess these tools’ effectiveness in promoting genetic counseling uptake and informed and shared decision making about genetic testing. Discussion If found to be effective, these tools can help integrate genomic risk assessment into primary care and, ultimately, help expand access to risk-appropriate breast cancer prevention options to a broader population of high-risk women. Trial registration This trial is retrospectively registered with ClinicalTrials.gov Identifier: NCT03470402 : 20 March 2018

Knowledge Gaps, Barriers, and Facilitators to Fertility Preservation Counseling Among Oncology Nurses Managing the Care of Newly Diagnosed Cancer Patients

Newly diagnosed cancer patients are inconsistently counseled about the infertility risks associated with oncologic treatments and the fertility preservation options currently available. Oncology nurses are placed in a unique position to introduce fertility topics with oncology patients; however, several barriers prevent counseling on this subject. The purpose of this paper is to determine the knowledge gaps, barriers, and facilitators of counseling newly diagnosed reproductive-aged cancer patients about fertility issues before cancer treatments among oncology nurses. An anonymous web-based, cross-sectional survey was accessed from August 2018-November 2018 and completed by oncology nurses employed in the medical oncology and infusion centers of a large multicenter cancer institution. The survey consisted of five elements: study consent, demographic information and general fertility questions, the American Society of Clinical Oncology (ASCO) 2013 clinical practice guideline questions, a validated knowledge tool to assess general fertility knowledge, and a validated oncology fertility preservation survey to determine barriers and facilitators to counseling patients about fertility issues. Thirty-eight participants completed the survey in its entirety, and the collected data were reviewed and analyzed. The majority of participants were full-time, Caucasian oncology nurses with an oncology experience of 1-5 years or 6-10 years. All of the participants were female. The majority of oncology nurses reported that they were unfamiliar with the clinical guidelines related to fertility preservation and oncology patients. The average baseline knowledge score using the validated knowledge tool was 7.1 (out of 13 questions). The higher domain scores in self-awareness, confidence, and external barriers from the fertility preservation survey indicated that self-perceived barriers and self-related preparedness hindered oncology nurse counseling on fertility topics. The findings suggest that oncology nurses would benefit from comprehensive training about fertility issues that impact oncology patients to adequately and confidently counsel these patients on this topic. Presenting these topics to patients who are interested in future fertility and those that are physiologically stable enough to pursue fertility preservation options will allow them the opportunity to make informed decisions about their future fertility and quality of life before possible sterilizing treatments

Discussing uncertainty and risk in primary care: recommendations of a multi-disciplinary panel regarding communication around prostate cancer screening.

BackgroundShared decision making improves value-concordant decision-making around prostate cancer screening (PrCS). Yet, PrCS discussions remain complex, challenging and often emotional for physicians and average-risk men.ObjectiveIn July 2011, the Centers for Disease Control and Prevention convened a multidisciplinary expert panel to identify priorities for funding agencies and development groups to promote evidence-based, value-concordant decisions between men at average risk for prostate cancer and their physicians.DesignTwo-day multidisciplinary expert panel in Atlanta, Georgia, with structured discussions and formal consensus processes.ParticipantsSixteen panelists represented diverse specialties (primary care, medical oncology, urology), disciplines (sociology, communication, medical education, clinical epidemiology) and market sectors (patient advocacy groups, Federal funding agencies, guideline-development organizations).Main measuresPanelists used guiding interactional and evaluation models to identify and rate strategies that might improve PrCS discussions and decisions for physicians, patients and health systems/society. Efficacy was defined as the likelihood of each strategy to impact outcomes. Effort was defined as the relative amount of effort to develop, implement and sustain the strategy. Each strategy was rated (1-7 scale; 7 = maximum) using group process software (ThinkTank(TM)). For each group, intervention strategies were grouped as financial/regulatory, educational, communication or attitudinal levers. For each strategy, barriers were identified.Key resultsHighly ranked strategies to improve value-concordant shared decision-making (SDM) included: changing outpatient clinic visit reimbursement to reward SDM; development of evidence-based, technology-assisted, point-of-service tools for physicians and patients; reframing confusing prostate cancer screening messages; providing pre-visit decision support interventions; utilizing electronic health records to promote benchmarking/best practices; providing additional training for physicians around value-concordant decision-making; and using re-accreditation to promote training.ConclusionsConference outcomes present an expert consensus of strategies likely to improve value-concordant prostate cancer screening decisions. In addition, the methodology used to obtain agreement provides a model of successful collaboration around this and future controversial cancer screening issues, which may be of interest to funding agencies, educators and policy makers

Breast Cancer Risk Assessment and Primary Prevention Advice in Primary Care: A Systematic Review of Provider Attitudes and Routine Behaviours

Implementing risk-stratified breast cancer screening is being considered internationally. It has been suggested that primary care will need to take a role in delivering this service, including risk assessment and provision of primary prevention advice. This systematic review aimed to assess the acceptability of these tasks to primary care providers. Five databases were searched up to July–August 2020, yielding 29 eligible studies, of which 27 were narratively synthesised. The review was pre-registered (PROSPERO: CRD42020197676). Primary care providers report frequently collecting breast cancer family history information, but rarely using quantitative tools integrating additional risk factors. Primary care providers reported high levels of discomfort and low confidence with respect to risk-reducing medications although very few reported doubts about the evidence base underpinning their use. Insufficient education/training and perceived discomfort conducting both tasks were notable barriers. Primary care providers are more likely to accept an increased role in breast cancer risk assessment than advising on risk-reducing medications. To realise the benefits of risk-based screening and prevention at a population level, primary care will need to proactively assess breast cancer risk and advise on risk-reducing medications. To facilitate this, adaptations to infrastructure such as integrated tools are necessary in addition to provision of education

Development of a Shared Decision-Making Program Theory: A Realist Synthesis Examining Contexts and Mechanisms to Engagement

Purpose: Shared Decision-making (SDM) is a style of medical decision-making that focuses on balancing the relationship between patients, physicians, and other key players. SDM is purported to improve patient and system outcomes; however, the potential effectiveness is challenged in part due to gaps in the current literature between theory and implementation. With my team, I conducted a realist synthesis of SDM literature to identify “In which situations, how, why, and for whom does SDM between patients and health care providers contribute to improved patient-centered decisions?” Method: We conducted a seven step iterative process, including: preliminary theory development, establishment of a search strategy, selection and appraisal of literature, data extraction, identification of formal theories, analysis and synthesis of extracted results from literature, and formation of a revised program theory with the input of patients, physicians, nurse navigators, and policy makers from a stakeholder session Results: We developed a program theory comprised of eight complex, interrelated mechanisms, three contexts, and a single outcome of engagement in SDM. Conclusion: Our realist synthesis produced a program theory for SDM through the identification of mechanisms which shape the characteristics of when, how, and why SDM will, and will not, work. This research hypothesizes that by facilitating high engagement of SDM, medical consultations will lead to informed, patient-centered decisions

The use of outcome information in shared decision-making about surveillance after breast cancer

Thanks to major advances in early detection and treatment, the survival of people with breast cancer has significantly increased in recent decades. In addition, the incidence of breast cancer is rising. These developments mean an increasing number of people who have hadbreast cancer (prevalence) and that make use of follow-up care after curative treatment. Follow-up after breast cancer consists of aftercare and post-treatment surveillance. Aftercare includes providing information, guidance, detecting immediate or late effects of disease and treatment, addressing these complaints and symptoms, and attention for social consequences. Post-treatment surveillance focuses on detecting new manifestations of the treated breast cancer or new associated malignancies. Until now, the surveillance for all breast cancer patients was ‘one-size-fits-all’: annual imaging (mammography or MRI) and a physical examination for at least five years after surgery. However, research shows that the risks of breast cancer recurrence differ per patient and that there are possibilities for personalising surveillance since the intensity of surveillance can safely be decreased for patients with low risks for recurrences.The process of shared decision-making (SDM) can support the delivery of value-based health care (VBHC) as it can strengthen the position of patients by tailoring information to patient needs and by improving engagement and outcomes, whilst reducing costs and health care burden by avoiding unnecessary treatments or care procedures that do not align with patients’ goals and values. SDM can be supported using patient decision aids (PtDAs) that provide structured information and help patients to consider and prioritise their preferences and choices. PtDAs can be even more valuable when they contain personalised information about outcomes of care (so-called ‘outcome information’). For SDM about personalised surveillance after breast cancer it may be beneficial to develop a PtDA which contains outcome information regarding the individual risks for recurrences. These risks can be estimated using the INFLUENCE 2.0-nomogram.

Healthcare Providers’ Perceptions Of Barriers And Facilitators To Making A Recommendation To Screen For Colorectal Cancer

ABSTRACT Background. Colorectal cancer (CRC) is the third most commonly diagnosed type of cancer in North Dakota. It also ranks second in late-stage diagnosis among all cancers. High quality screening tests such as colonoscopy have shown to reduce CRC incidence significantly, but screening rates in North Dakota remain low. The literature is consistent in that a recommendation by a healthcare provider is the most influential factor in a patient’s decision to screen. Purpose. The purpose of this dissertation was to understand how healthcare providers perceive the barriers and facilitators that affect their decision to make CRC screening recommendations to patients. Identifying educational concepts and strategies that can be used to address needs and gaps uncovered in this study is also a priority. Sample. A total of 43 out of 55 clinics that provide primary care services in North Dakota was invited to participate in the survey. The sample was one of convenience as the survey was distributed to the 201 healthcare providers practicing at these clinics. There was a total of 74 completed responses for a response rate of 37 percent. Method. A survey was used to collect data from participants on their perceptions of patient-, provider-, and systems-level barriers and facilitators. Descriptive statistics were used to analyze perceptions of providers on individual items. Directional t-tests were used to test for an effect between the independent variable of whether the provider had completed a CRC screening test or not and the dependent variables of the six constructs of patient-, provider-, and systems-level barriers and facilitators. Linear regression was used to test for a correlation between providers’ attitudes on the efficacy of CRC screening tests and the six constructs. Results. No statistical significance was found in the analysis using t-tests. Significance was found using linear regression between the independent variable of the provider’s attitude on the efficacy of immunochemical fecal occult blood test/fecal immunochemical test (iFOBT/FIT) and the constructs of systems barriers, provider facilitators, and systems facilitators. The descriptive analysis did reveal practical insight that can be used to address needs and gaps as well as enhance current practice. Keywords: barriers, cancer, colorectal, education, facilitators, healthcare providers, screening, test