Roles and recommendations from primary care physicians towards managing low-risk breast cancer survivors in a shared-care model with specialists in Singapore-a qualitative study.

BackgroundBreast cancer is prevalent and has high cure rates. The resultant increase in numbers of breast cancer survivors (BCS) may overwhelm the current oncology workforce in years to come. We postulate that primary care physicians (PCPs) could play an expanded role in comanaging survivors, provided they are given the appropriate tools and training to do so.ObjectiveTo explore the perspectives of PCPs towards managing BCS in a community-based shared-care programme with oncologists.MethodsEleven focus groups and six in-depth interviews were conducted with seventy PCPs recruited by purposive sampling. All sessions were audio-recorded, transcribed verbatim and coded by three independent investigators. Thematic data analysis was performed and the coding process facilitated by NVivo 12.ResultsMajority of PCPs reported currently limited roles in managing acute and non-cancer issues, optimizing comorbidities and preventive care. PCPs aspired to expand their role to include cancer surveillance, risk assessment and addressing unmet psychosocial needs. PCPs preferred to harmonize cancer survivorship management of their primary care patients who are also BCS, with defined role distinct from oncologists. Training to understand the care protocol, enhancement of communication skills, confidence and trust were deemed necessary. PCPs proposed selection criteria of BCS and adequacy of their medical information; increased consultation time; contact details and timely access to oncologists (if needed) in the shared-care programme.ConclusionsPCPs were willing to share the care of BCS with oncologists but recommended role definition, training, clinical protocol, resources and access to oncologist's consultation to optimize the programme implementation

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

A conceptual framework and protocol for defining clinical decision support objectives applicable to medical specialties.

BackgroundThe U.S. Centers for Medicare and Medicaid Services established the Electronic Health Record (EHR) Incentive Program in 2009 to stimulate the adoption of EHRs. One component of the program requires eligible providers to implement clinical decision support (CDS) interventions that can improve performance on one or more quality measures pre-selected for each specialty. Because the unique decision-making challenges and existing HIT capabilities vary widely across specialties, the development of meaningful objectives for CDS within such programs must be supported by deliberative analysis.DesignWe developed a conceptual framework and protocol that combines evidence review with expert opinion to elicit clinically meaningful objectives for CDS directly from specialists. The framework links objectives for CDS to specialty-specific performance gaps while ensuring that a workable set of CDS opportunities are available to providers to address each performance gap. Performance gaps may include those with well-established quality measures but also priorities identified by specialists based on their clinical experience. Moreover, objectives are not constrained to performance gaps with existing CDS technologies, but rather may include those for which CDS tools might reasonably be expected to be developed in the near term, for example, by the beginning of Stage 3 of the EHR Incentive program. The protocol uses a modified Delphi expert panel process to elicit and prioritize CDS meaningful use objectives. Experts first rate the importance of performance gaps, beginning with a candidate list generated through an environmental scan and supplemented through nominations by panelists. For the highest priority performance gaps, panelists then rate the extent to which existing or future CDS interventions, characterized jointly as "CDS opportunities," might impact each performance gap and the extent to which each CDS opportunity is compatible with specialists' clinical workflows. The protocol was tested by expert panels representing four clinical specialties: oncology, orthopedic surgery, interventional cardiology, and pediatrics

In the Spotlight

In September, 10 advanced practice nurses from the Department of Surgery gathered for a lunchtime kick-off meeting to form a Nurse Practitioners (NPs) & Physician Assistants (PAs) Professionalism and Scholarship Working Group. This initiative is an important career development component and has been meeting on a monthly basis to discuss issues in clinical practice, explore potential clinical research projects, foster CV development, and address professional practice concerns. Thus far, two projects have been submitted for small grant consideration, several presentations have been developed and two members are collaborating on publishing an online continuing education module for NPs. All Department of Surgery NPs and PAs are invited. Please contact: [email protected]

The Contribution of Patient Reported Outcome Measures to Shared Decision-Making in Radiation Oncology at a Midwestern Comprehensive Cancer Center

Background. Chronic diseases, such as lung cancer, require a provider-patient relationship developed over time. This relationship fosters shared decision-making (SDM), a collaborative, dynamic information exchange and analysis between provider and patient regarding treatment and desired outcomes. Established benefits to SDM include an improved quality of life and decreased anxiety and depression. Despite established benefits, recent research suggests radiation oncologists are not engaging in SDM. A decision-aid tool utilizing patient reported outcome measures may increase SDM between radiation oncologists and patients with lung cancer. Patient-reported outcome measures, wherein the patient provides direct assessment of their health and quality of life, can inform and initiate SDM. This study investigated the design and implementation of a collaborative decision-aid tool for patients with lung cancer at a Midwestern cancer center as informed by stakeholders, practice considerations, and the evidence base. Objectives. The primary objective was to develop a collaborative decision-aid tool, using patient-reported outcome measures, that can be implemented in an academic radiation oncology clinic. Secondary objectives then assessed the tool’s impact through surrogates of shared decision making (add-on oncology visits, concomitant medication prescriptions), medical management (adverse events, radiation therapy compliance, chemotherapy compliance) and emergent care and its costs (emergency room visits and estimated costs, inpatient admissions and estimated costs). The hypothesized result was a decision aid designed to increase collaborative communication between radiation oncologists and patients will result in improved shared decision making, yielding better medical management and patient outcomes and reducing emergent care costs. Lastly, an implementation roadmap provided information on experienced barriers, facilitators, and considerations for performance objectives. Materials and Methods. A sequential exploratory mixed methods design was employed. The qualitative strand explored how stakeholders, practice considerations, and the evidence base informed the design and installation of an ideal collaborative decision-aid tool. Semi-structured interviews were completed with both patients who completed radiation therapy for lung cancer and their radiation oncologist. Interviews were coded and evaluated for themes. Interviews were transcribed verbatim, coded using Atlas.ti software, and analyzed thematically and visually. The results of this analysis, combined with information from the literature base and implementation stakeholders, was used to inform design of the collaborative decision-aid tool that was installed employing the principles of clinical implementation using the plan-do-study-act (PDSA) implementation cycle model. Simple descriptive analysis was performed on objective measures. Mixed analysis included data display, comparison, and integration. Results. Six patients and six radiation oncologists participated in the semi-structured interviews. Interviews provided insights that patients did not know what to ask of their radiation oncologists, prioritized survival over reduced side effects, and minimized complaints to their radiation oncologists, often to their detriment. Interviews yielded feedback on commonly used patient reported outcome instruments, identifying context as important and the recall timeframe as difficult. Commonly patient-identified adverse events of concern were fatigue, dyspnea, vomiting, and dysphagia. Radiation oncologists identified a patient’s personality as critical to care and translating responses and symptoms to adverse events of treatment. For this reason, numeric scales were not endorsed as they were seen as ambiguous and lacking context. With this feedback, a collaborative decision-aid tool was designed that focused on adverse events of interest (nausea, vomiting, fatigue, dyspnea, chest pain, weight loss). Rather than numeric scales, responses provided granular context that clued physicians to medical needs (i.e., “I cannot walk to my appointment,” “It hurts when I eat,” “I am not vomiting but I’m not hungry”). This tool was implemented as a quality initiative project for pragmatic impact. Four patients were assigned the tool during the first PDSA implementation cycle. The first follow-up evaluation meeting identified four critical outcomes for the next implementation cycle: how to identify which consults require the decision-aid, how the need for the decision-aid on doctor visits is consistently provided to scheduling, how unplanned visits/special complaints are addressed with regard to the decision-aid, and what actions are necessary if the patient leaves prior to the decision-aid being reviewed. Mixed analysis provided direction for next steps in implementation, tool design, and quantitative data measures. The primary concern, increase in time expended per clinic visit, was not supported by the limited data available from the first implementation cycle. Conclusion. Implementation of collaborative decision-aid within the radiation oncology clinic is feasible without disruption of the on-treatment visit time. Radiation oncologists can use the tool as a guide for routine on-treatment visit review, so that it is harmonized with their routine practice. Care should be taken during implementation to ensure all stakeholders are included in the tool’s implementation and that desired outcomes are appropriately identified to truly capture what impact the tool has, if any, on clinical outcomes. Focusing on the patient with the goal of improving their experience will guide collaborative decision-aid tool adaptation, implementation, and uptake

Oncology Outpatient and Provider Responses to a Computerized Symptom Assessment System

Purpose/Objectives: To assess patient and provider responses to a computerized symptom assessment system. Design: Descriptive, longitudinal study with retrospective, longitudinal medical records review. Setting: University-based National Cancer Institute-designated outpatient cancer center. Sample: 80 oncology outpatients receiving chemotherapy, 8 providers, and 30 medical records. Methods: Patients completed the computerized assessment during three chemotherapy follow-up clinic appointments (times 1, 2, and 3). Patient usability was recorded via an observer checklist (ease of use) and the computer (completion time). Patient satisfaction and impact were assessed during telephone interviews two to three days after times 1 and 3 only. Provider usability and impact were assessed at the end of the study using a questionnaire and focus groups, whereas effect on provider documentation was assessed through chart audits. Main Research Variables: Patient usability (ease of use, completion time), satisfaction, and impact; provider usability and impact. Findings: Patients reported good usability, high satisfaction, and modest impact on discussions with their providers. Providers reported modest usability, modest impact on discussions with patients, and had varied reactions as to how the system affected practice. Documentation of symptoms was largely absent before and after implementation. Conclusions: This system demonstrated good usability and satisfaction but had only a modest impact on symptom-related discussions and no impact on documentation. Implications for Nursing: A computerized system can help address barriers to symptom assessment but may not improve documentation unless it can be integrated into existing medical records systems

Implementing Serious Illness Conversations in a Gastrointestinal Oncology Clinic: A mixed method evaluation of a quality improvement initiative in a Boston Hospital

INTRODUCTION: Many times, advanced care planning happens too late in patients with metastatic gastrointestinal cancer, patients and families are not educated on prognostic awareness and are often not well and poorly equipped to make informed end of life decisions. AVAILABLE KNOWLEDGE: A Serious Illness Conversation guide was developed and implemented in a Boston hospital to aid practitioners (oncology nurse practitioners and oncologists) in facilitating advanced care planning. The aim of this study was to describe provider experience with the conversation guide and understand facilitators and barriers to implementation of advanced care planning. METHODS: The Plan Do Study Act Method of quality improvement was used for this project. In a Boston gastrointestinal oncology clinic, three medical oncologists and two oncology nurse practitioners were trained in December 2018 on use and documentation of A Serious Illness Conversation Guide. We then reviewed the electronic medical records of 121 patients with metastatic gastrointestinal cancer, with a final sample size of 72 patients, receiving their care in a solo hospital to identify documentation of ACP, as well as health care utilization outcomes. Three cohorts were chosen for this analysis: Cohort 1: 25 newly diagnosed GI oncology patients, medical records were reviewed one year prior to the Serious Illness Conversation Training of providers (N = 25); Cohort 2: Medical records were reviewed on an additional 25 newly diagnosed GI oncology patients. They were eligible if they had newly diagnosed metastatic gastrointestinal cancer, this was three months prior to implementation of the Serious Illness Conversation training (N = 25); and the final Cohort, number 3: was a consecutive medical record review of 25 newly diagnosed patients with metastatic gastrointestinal cancer of the same trained 5 providers. This groups chart were reviewed three months after implementation of the training (N=25). We examined rates of ACP documentation and health care utilization (ED visits, hospitalizations, ICU admissions, code status, and ACP documentation and hospice use) in these cohorts. Literature review and listserv query were conducted to identify serious illness conversations. INTERVENTION: Serious Illness Conversation Training was performed for each individual provider. Post training for 3 months, January 2019 - March 2019, weekly individual support was given to the 5 providers to reinforce workflow and documentation. Individual interviews were conducted post training in addition to chart reviews at 3 separate time points. RESULTS: We enrolled 5 clinicians (3 medical oncologists and 2 oncology nurse practitioners) working in Gastrointestinal Oncology for Serious Illness Conversation Training. A chart review was performed on newly diagnosed patients with GI oncology There were no differences between groups from time of diagnosis to an advanced care planning conversation. Patients in the post-intervention cohort had a shorter time from diagnosis to ACP (advanced care planning) conversation compared to those diagnosed one year prior to the intervention (B = -293.58, 95%CI -1003, 446, P = 0.407), but this was not statistically significant. CONCLUSIONS: Training a small cohort of clinicians in Serious Illness Conversations, documentation in the EHR and coaching has aided these practitioners in implementation of formal advanced care planning that is accessible and visible. This study was conducted in GI oncology to demonstrate feasibility, barriers and facilitators to use of this guide. It also has illustrated that it is possible for earlier serious illness conversations leading to more informed advanced care planning

Longitudinal investigation of prognostic communication: Feasibility and acceptability of studying serial disease reevaluation conversations in children with high-risk cancer

BACKGROUND: Prospective investigation of medical dialogue is considered the gold standard in prognostic communication research. To the authors' knowledge, the achievability of collecting mixed methods data across an evolving illness trajectory for children with cancer is unknown. METHODS: The objective of the current study was to investigate the feasibility and acceptability of recording sequential medical discussions at disease reevaluation time points for children with high‐risk cancer. Mixed methods data (ie, surveys, interviews, checklists, and chart reviews) corresponding to each disease reevaluation conversation also were captured in real‐time for 34 patients across 24 months at an academic pediatric cancer center. RESULTS: All eligible oncology clinicians (65 of 65 clinicians; 100%) and the majority of eligible patient/parent dyads (34 of 41 dyads; 82.9%) enrolled on the study; of 200 disease reevaluation discussions, 185 discussions (92.5%) were recorded, totaling >3300 minutes of recorded medical dialogue. Longitudinal data were captured for 31 of 34 patient/parent dyads (91.2%). The vast majority of study materials were completed, including 138 of 139 nonverbal communication checklists (99.3%), all 49 oncologist surveys (100%), 40 of 49 parent surveys (81.6%), all 34 oncologist interviews (100%), and 24 of 34 parent interviews (70.6%). Only 1 parent reported participation to be a “very” distressing experience, no parents believed that their level of distress warranted speaking with a psychosocial provider, and the majority of parents (18 of 29 parents; 62.1%) described study participation as “somewhat” or “very” useful to them. CONCLUSIONS: The prospective, longitudinal investigation of prognostic communication using a mixed methods approach appears to be feasible and acceptable to clinicians, patients, and families. The study of sensitive content can be accomplished without causing undue participant burden or harm, thereby enabling further advancement of communication research

The implementation of a physical activity and nutrition protocol into the electronic medical record of adolescent pediatric cancer survivors in a long-term follow-up clinic: sPACE+

Thesis (M.A.)--Boston UniversityBetween 1975 and 2006, childhood cancer survival rates have increased over 50%, resulting in a much larger population of childhood cancer survivors. As adults, childhood cancer survivors have poorer general health and significantly more health problems which can be linked to toxicities encountered during their treatments. They are more likely to be obese, have endocrine abnormalities, and suffer from hypertension and dyslipidemia. While their leading cause of death 15-plus years after finishing treatment is a second cancer, they also have higher rates of other chronic diseases such as diabetes, insulin resistance, cardiovascular disease, and pulmonary disease. Despite the clear evidence showing poorer health outcomes for childhood cancer survivors, many adolescents do not perceive that they are at increased risk for chronic diseases. Between 2006 and 2008, researchers at the University of Hawaii Cancer Center conducted focus groups that revealed that parents and adolescent survivors lacked knowledge about cancer survivors' increased chronic disease risk, and pediatric oncologists were frustrated with parents' and survivors' unwillingness to modify health risk behaviors and lacked experience with behavior change counseling. Patient-centered Assessment and Counseling for Exercise + Nutrition (PACE+) is a validated, evidence-based physical activity and nutrition intervention that used the Transtheoretical Model to stage patients in varying levels of change. We modified PACE+ materials to make them suitable for adolescent cancer survivors in Hawaii and are calling this modified program Patient-centered Assessment and Counseling for Exercise+ Nutrition for Survivors (sPACE+). Surveys administered to clinicians at the Kapiolani Comprehensive Children's Cancer Center indicated that providers had low levels of consistent physical activity and nutrition counseling, did not take the patient's willingness to change into account when making health behavior recommendations, had several barriers to diet and physical activity counseling, and had low perceived success creating health behavior change with their patients. To address these issues, we modified the original PACE+ program and incorporated it into the EMR by creating a flowsheet and a progress note template. The sPACE+ system is a tool that informs the provider of their patient's physical activity or nutrition status, tells them what to do and what to say, and provides them with written materials relevant to the patient's interests and willingness to change. At the conclusion of this project's usability study, we will administer staff surveys to assess how well the sPACE+ protocol fit into their long-term care delivery system. It is our hope that the sPACE+ system will have great perceived success by the clinic staff and minimal intrusion on their clinic workflow. The implementation of protocols into the EMR is an innovative idea that has shown considerable promise. If EMR-based interventions like sPACE+ are found to be successful, the potential exists for them to be quickly and easily shared between users of the same system at different institutions