Facilitating practitioners to deliver self-management support to cancer survivors: development and co-design of a theory-based intervention informed by contexts and mechanisms

Background Older cancer survivors have physical and psychosocial problems after completing cancer treatment which are not adequately addressed by secondary care teams. Enabling older cancer survivors to self-manage problems after cancer treatment is essential for optimising their health and wellbeing. This thesis aimed to design an intervention to facilitate primary care teams to provide self-management support to older cancer survivors. Methods Underpinned by scientific realism and behavioural science, this research involved three empirical studies: a cross-sectional study to estimate the prevalence of cancer treatment-related problems in older cancer survivors and overall care satisfaction, a realist review, and a co-design study to understand and address the barriers and enablers for facilitating primary care practitioners to provide self-management support. Results Half of older cancer survivors experienced physical and psychosocial problems after cancer treatment. Of these, 82% experienced physical, 69% psychological and 51% social problems. Perceived support from secondary care teams to manage physical, psychological and social problems was rated as adequate by 64%, 50% and 28%, respectively. Key enablers for facilitating practitioners to provide self-management support were knowledge and communication skills to engage cancer survivors in discussions about self-management, practitioners feeling that their role and responsibilities included self-management support, the organisation prioritising self-management support, and health system configuration to integrate self-management support into routine care. A structured pathway was co-designed to facilitate primary care teams to provide self-management support. This will involve using the knowledge and skills of existing team members to identify patients with unmet needs who may benefit from additional support, identifying local self-management resources and signposting patients to existing provision of information and care, and a mechanism for annual patient follow-up. Conclusion The intervention developed maximises the role of existing primary care teams and optimises current processes. The next step is to operationalise the intervention and evaluate efficacy at facilitating delivery of self-management support

Facilitating healthcare practitioners to deliver self-management support in adult cancer survivors: a realist review

Background: Supporting cancer survivors in self-management can empower them to take an active role in managing the long-term physical and psychosocial consequences of cancer treatment. Healthcare practitioners are key to supporting patients to self-manage, however, they do not routinely engage in these discussions. Objective(s): This review aimed to establish what works for whom and in what circumstances in relation to facilitating healthcare practitioners to provide self-management support in people living with long-term consequences of cancer treatment. Methods: The review follows five steps: define the review's scope, develop initial programme theories, evidence search, selection and appraisal, and data extraction and synthesis. Database searches of Medline, EMBASE, CINAHL, Scopus, PsycINFO, ERIC and AMED databases, to September 2019 were supplemented with practitioner surveys. Insights into the mechanisms that operate in particular contexts to produce successful outcomes were illustrated using realist programme theories, developed using the Theoretical Domains Framework. Data selection was based on relevance and rigour. Data were extracted and synthesised iteratively to illuminate causal links between contexts, mechanisms and outcomes. Results: Five programme theories were identified from 20 included articles and seven practitioner surveys: practitioners will engage patients in discussions about self-management if they have appropriate (1) knowledge and (2) consultations skills, (3) a clear understanding of their self-management support role and responsibilities, and if (4) organisational strategies and (5) health system configuration enable integration into routine care. The mechanisms facilitating practitioners to support self-management were practitioner confidence, mutual trust and shared responsibility between practitioners and cancer survivors, organisational prioritisation and ease of delivery of self-management support. Conclusion: The findings articulate the necessary components for embedding self-management support into routine cancer care. Operationalisation of these components into effective self-management support interventions will require reconfiguration of pathways and adaptation for local context, using strategies such as quality improvement and co-design to guide intervention development, implementation and evaluation

Realist review protocol for understanding the real-world barriers and enablers to practitioners implementing self-management support to people living with and beyond cancer

Introduction: Self-management support can enable and empower people living with and beyond cancer to take an active role in managing long-term consequences of cancer treatment. Healthcare professionals are key to promoting patients to self-manage, however, they do not routinely engage in these discussions. This review aims to understand what works for whom and in what circumstances in relation to practitioners engaging with supporting people living with and beyond cancer to self-manage long-term consequences of systemic anticancer treatment. Methods and analysis: We will follow five steps for undertaking the realist review: (1) define the review scope; (2) develop initial programme theories; (3) evidence search, (4) selection and appraisal and (5) data extraction and synthesis. We will combine an informal literature search with a theory-based approach, using the Theoretical Domains Framework, and stakeholder feedback to develop initial programme theories. We will search Medline, EMBASE, CINAHL, SCOPUS, PsycINFO, ERIC and AMED databases to September 2019, and supplement this with citation tracking, grey literature and practitioner surveys. Data selection will be based on relevance and rigour. Data will be extracted and synthesised iteratively, and causal links between contexts, mechanism and outcomes illuminated in the process. The results will be reported according to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) quality and publication standards Ethics and dissemination: We have received ethical approval through the Research Ethics Committee, Faculty of Medicine and Health Sciences, University of East Anglia (ref 201819 – 124). We will disseminate to the research community through conference presentations and a peer-reviewed journal article. We will work with health care organisations, cancer charities and patients to agree a strategy for disseminating to these groups. PROSPERO registration number: CRD4201912091

Developing a core outcome set for evaluating medication adherence interventions for adults prescribed long-term medication in primary care

Background: Approximately half of people prescribed medications do not take them as prescribed. There is a significant unmet need regarding the barriers to medication adherence not being addressed in primary care. There is no agreement on which outcomes should be measured and reported in trials of medication adherence interventions. Objective: To develop a core outcome set (COS) for trials of medication adherence interventions in primary care for adults prescribed medications for long-term health conditions. Methods: A list of potentially relevant outcomes from the literature was developed. Using a two-round Delphi survey of stakeholder groups representing patients and their carers; primary care staff; and academic researchers with an interest in medication adherence; each outcome was scored in terms of importance for determining the effectiveness of medication adherence interventions in primary care. This was followed by two consensus workshops, where importance, as well as feasibility and acceptability of measurement, were considered in order to finalise the COS. Results: One hundred and fifty people took part in Delphi Round 1 and 101 took part in Round 2. Eight people attended the workshops (four attendees per workshop). Seven outcomes were identified as most important, feasible and acceptable to collect in medication adherence trials: Health-related quality of life, number of doses taken, persistence with medicines, starting (initiating) a medicine, relevance of the medication adherence intervention for an individual, mortality, and adverse medicine events. Conclusions: This COS represents the minimum outcomes that should be collected and reported in all medication adherence trials undertaken in primary care. When developing and finalizing the COS, feasibility and acceptability of collection of outcomes has been considered. In addition to the COS, medication adherence trials can choose to include outcomes to suit their specific context such as the health condition associated with their medication adherence intervention

Adapting care for older cancer patients during the COVID-19 pandemic: Recommendations from the International Society of Geriatric Oncology (SIOG) COVID-19 Working Group

The COVID-19 pandemic poses a barrier to equal and evidence-based management of cancer in older adults. The International Society of Geriatric Oncology (SIOG) formed a panel of experts to develop consensus recommendations on the implications of the pandemic on several aspects of cancer care in this age group including geriatric assessment (GA), surgery, radiotherapy, systemic treatment, palliative care and research. Age and cancer diagnosis are significant predictors of adverse outcomes of the COVID-19 infection. In this setting, GA is particularly valuable to drive decision-making. GA may aid estimating physiologic reserve and adaptive capability, assessing risk-benefits of either providing or temporarily withholding treatments, and determining patient preferences to help inform treatment decisions. In a resource-constrained setting, geriatric screening tools may be administered remotely to identify patients requiring comprehensive GA. Tele-health is also crucial to ensure adequate continuity of care and minimize the risk of infection exposure. In general, therapeutic decisions should favor the most effective and least invasive approach with the lowest risk of adverse outcomes. In selected cases, this might require deferring or omitting surgery, radiotherapy or systemic treatments especially where benefits are marginal and alternative safe therapeutic options are available. Ongoing research is necessary to expand knowledge of the management of cancer in older adults. However, the pandemic presents a significant barrier and efforts should be made to ensure equitable access to clinical trials and prospective data collection to elucidate the outcomes of COVID-19 in this population

It's time for comprehensive polypharmacy reviews for older people with cancer

The number of older people with cancer is growing and so is their risk of harmful polypharmacy — care for this expanding group of patients must improve

How-to guide for medication reviews in older adults with cancer: A Young International Society of Geriatric Oncology and Nursing & Allied Health Interest Group initiative

For patients with polypharmacy or potentially inappropriate medication (PIM) use identified on geriatric assessment, a medication review is recommended. The medication review aims to ensure that the potential benefits of medication outweigh any potential harms and ensures the patient is receiving medication to effectively treat their medical conditions while minimizing risk of toxicity. The medication review encompasses: (1) collecting information to identify medication indications, efficacy and side effects, (2) evaluating adherence, (3) identifying PIMs, (4) identifying drug interactions, and (5) deprescribing. This paper provides the “how-to” guide to conduct a high-quality medication review by the cancer care multidisciplinary team

How-to guide for medication reviews in older adults with cancer: A Young International Society of Geriatric Oncology and Nursing & Allied Health Interest Group initiative

For patients with polypharmacy or potentially inappropriate medication (PIM) use identified on geriatric assessment, a medication review is recommended. The medication review aims to ensure that the potential benefits of medication outweigh any potential harms and ensures the patient is receiving medication to effectively treat their medical conditions while minimizing risk of toxicity. The medication review encompasses: (1) collecting information to identify medication indications, efficacy and side effects, (2) evaluating adherence, (3) identifying PIMs, (4) identifying drug interactions, and (5) deprescribing. This paper provides the “how-to” guide to conduct a high-quality medication review by the cancer care multidisciplinary team.</p

Optimising medications for patients with cancer and multimorbidity: The case for deprescribing

The majority of patients diagnosed with cancer are aged over 65 years and have two or more chronic conditions in addition to cancer and the risk of chronic conditions increases further after cancer. The presence of multimorbidity adds complexity to care, as patients' goals of care and the focus of treatment can change with a diagnosis of cancer. Multimorbidity is frequently associated with polypharmacy, the use of potentially inappropriate medications, the presence of adverse drug reactions and potential drug–drug interactions: all of which impact on health outcomes and the cost of care. Consequently, it is vital that a systematic approach is taken to regularly review cancer patients' medication regimens to ensure that they support an optimal balance of benefits with acceptable levels of harm. Several patient and clinician resources are presented to guide the process of medication review and deprescribing