Development, implementation and evaluation of the acceptability and feasibility of a shared cancer follow-up model of care

Background The increasing incidence of cancer, coupled with improved survivorship, has increased the demand for cancer follow-up care and the need to find alternative models of care. International and national guidelines advocate for including general practitioners (GP) in cancer follow-up care. Barriers to implementing shared care into practice include having clinical assessment protocols for GPs, and suitable health technology to allow two-way communication to enable oncologists to continue overseeing care. To address these barriers, this thesis aimed to develop and implement a novel shared cancer follow-up model of care, and evaluate the model\u27s acceptability and feasibility to patients, GPs and radiation oncologists (RO). Methods Following a systematic review, this research employed a concurrent triangulation mixed methods methodology. Participants were patients on radiotherapy follow-up care, their GP and RO. The intervention included patients’ visiting their GP twice and the GP completing a clinical assessment protocol, which was transferred with novel health technology to the RO in real-time to oversee care. The quantitative component included a cross-sectional population survey and two concordance studies. Data were analysed using frequencies, Cohen\u27s Kappa, Fleiss Kappa, logistic regression, and odds ratio. The qualitative component included semi-structured interviews, which were analysed thematically using the Theoretical Framework of Acceptability. Results were then synthesised to answer the overarching thesis\u27 aim. Results Four-hundred and fourteen surveys were returned (45% response rate) for the population survey. Acceptance for radiation oncology shared cancer follow-up care was high (80%). High Intervention Coherence and a positive Affective Attitude were significant predictive factors in accepting shared care. Eighty-three patient-RO dyads completed the remote monitoring concordance study. The lower-than-ideal response rate and fair to moderate patient-RO concordance meant results could not be used to support the model. Fifteen GP-RO dyads completed the follow-up clinical assessment concordance study, with moderate to almost perfect agreement, indicating the feasibility of the clinical assessment tool. Thirty-two pre-intervention and 28 post-intervention interviews were performed. This shared cancer follow-up model of care was acceptable and feasible for patients, GPs and ROs. Central to the acceptance was the clinical assessment protocol with an in-built rapid referral option, the health technology used to transfer the results securely from the GP to allow the RO to oversee care in real-time and collect outcome data. Acceptability and feasibility rely on the patients\u27 understanding of the benefits of shared care, the patients\u27 relationship with their GP, the oncologists\u27 endorsement of the model, the clinical assessments, and the health technology that allows the oncologist to continue to oversee care. Conclusion This thesis has shown a novel shared cancer follow-up model of care that is acceptable to patients, GPs and ROs, and feasible in practice. To support implementing this shared cancer follow-up model of care into practice, there is a need to review funding models, have continued support for health technology interfaces, support to ensure GPs have adequate recall systems in place, initial and ongoing support for GPs and oncologists in the form of a shared care coordinator, and support normalising the model into practice for all agents

Concordance between General Practitioners and Radiation Oncologists for Cancer Follow-Up Care

(1) Background: Patients treated with radiotherapy require follow-up care to detect and treat acute and late side effects, and to monitor for recurrence. The increasing demand for follow-up care poses a challenge for specialists and general practitioners. There is a perception that general practitioners do not have the specialised knowledge of treatment side effects and how to manage these. Knowing the concordance between general practitioner and oncologist clinical assessments can improve confidence in healthcare professionals. This study aimed to measure the level of agreement between general practitioners and radiation oncologists using a standardised clinical assessment; (2) Methods: a cross-sectional clinical practice study; sample aim of 20 breast, prostate or colorectal patients, three years post-radiotherapy treatment; their general practitioner and radiation oncologist; (3) Results: There was acceptable percent agreement (>75%) and a moderate to almost perfect agreement (Fleiss kappa) for all variables between the 15 general practitioner-radiation oncologist dyads; (4) Conclusions: The general practitioner and radiation oncologist concordance of a clinical follow-up assessment for radiation oncology patients is an important finding. These results can reassure both general practitioners and oncologists that general practitioners can provide cancer follow-up care. However, further studies are warranted to confirm the findings and improve reassurance for health professionals

Acceptability of a shared cancer follow-up model of care between general practitioners and radiation oncologists: A qualitative evaluation

Introduction: Facilitators to implement shared cancer follow-up care into clinical practice include mechanisms to allow the oncologist to continue overseeing the care of their patient, two-way information sharing and clear follow-up protocols for general practitioners (GPs). This paper aimed to evaluate patients, GPs and radiation oncologists (ROs) acceptance of a shared care intervention. Methods: Semi-structured interviews were conducted pre- and post intervention with patients that were 3 years post radiotherapy treatment for breast, colorectal or prostate cancer, their RO, and their GP. Inductive and deductive thematical analysis was employed. Results: Thirty-two participants were interviewed (19 patients, 9 GPs, and 4 ROs). Pre intervention, there was support for GPs to play a greater role in cancer follow-up care, however, patients were concerned about the GPs cancer-specific skills. Patients, GPs and ROs were concerned about increasing the GPs workload. Post intervention, participants were satisfied that the GPs had specific skills and that the impact on GP workload was comparable to writing a referral. However, GPs expressed concern about remuneration. GPs and ROs felt the model provided patient choice and were suitable for low-risk, stable patients around 2–3 years post treatment. Patients emphasised that they trusted their RO to advise them on the most appropriate follow-up model suited to their individual situation. The overall acceptance of shared care depended on successful health technology to connect the GP and RO. There were no differences in patient acceptance between rural, regional, and cancer types. ROs presented differences in acceptance for the different cancer types, with breast cancer strongly supported. Conclusion: Patients, GPs and ROs felt this shared cancer follow-up model of care was acceptable, but only if the RO remained directly involved and the health technology worked. There is a need to review funding and advocate for health technology advances to support integration. Patient or Public Contribution: Patients treated with curative radiotherapy for breast, colorectal and prostate cancer, their RO and their GPs were actively involved in this study by giving their consent to be interviewed

Concordance between General Practitioners and Radiation Oncologists for Cancer Follow-Up Care

(1) Background: Patients treated with radiotherapy require follow-up care to detect and treat acute and late side effects, and to monitor for recurrence. The increasing demand for follow-up care poses a challenge for specialists and general practitioners. There is a perception that general practitioners do not have the specialised knowledge of treatment side effects and how to manage these. Knowing the concordance between general practitioner and oncologist clinical assessments can improve confidence in healthcare professionals. This study aimed to measure the level of agreement between general practitioners and radiation oncologists using a standardised clinical assessment; (2) Methods: a cross-sectional clinical practice study; sample aim of 20 breast, prostate or colorectal patients, three years post-radiotherapy treatment; their general practitioner and radiation oncologist; (3) Results: There was acceptable percent agreement (\u3e75%) and a moderate to almost perfect agreement (Fleiss kappa) for all variables between the 15 general practitioner-radiation oncologist dyads; (4) Conclusions: The general practitioner and radiation oncologist concordance of a clinical follow-up assessment for radiation oncology patients is an important finding. These results can reassure both general practitioners and oncologists that general practitioners can provide cancer follow-up care. However, further studies are warranted to confirm the findings and improve reassurance for health professionals

Patients’ acceptance of a shared cancer follow-up model of care between general practitioners and radiation oncologists: A population-based survey using the theoretical Framework of Acceptability

Abstract Introduction International and national guidelines highlight the need for general practitioner involvement during and after active cancer treatment and throughout long-term follow-up care. This paper aimed to evaluate patients’ acceptance of radiation oncology shared follow-up care using the Theoretical Framework of Acceptability (TFA). Methods This cross-sectional study was conducted at two cancer care centres in the Illawarra Shoalhaven region of Australia. A sample of patients scheduled for a radiation oncology follow-up consultation in 2021 were sent a 32-point self-complete paper-based survey. Data were analysed using descriptive, parametric and non-parametric statistical analysis. This paper followed the Checklist for Reporting of Survey Studies (CROSS). Results Of the 414 surveys returned (45% response rate), the acceptance for radiation oncology shared cancer follow-up care was high (80%). Patients treated with only radiotherapy were 1.7 times more likely to accept shared follow-up care than those treated with multiple modalities. Patients who preferred follow-up care for fewer than three years were 7.5 times more likely to accept shared care than those who preferred follow-up care for five years. Patients who travelled more than 20 minutes to their radiation oncologist or to the rural cancer centre were slightly more likely to accept shared care than those who travelled less than twenty minutes to the regional cancer centre. A high understanding of shared care (Intervention Coherence) and a positive feeling towards shared care (Affective Attitude) were significant predictive factors in accepting shared radiation oncology follow-up care. Conclusion Health services need to ensure patient preferences are considered to provide patient-centred cancer follow-up care. Shared cancer follow-up care implementation should start with patients who prefer a shorter follow-up period and understand the benefits of shared care. However, patients’ involvement needs to be considered alongside other clinical risk profiles and organisational factors. Future qualitative research using the TFA constructs is warranted to inform clinical practice change

Patient self-reported follow-up for radiation oncology patients during COVID-19: feasibility and patient-clinician agreement

Introduction COVID-19 required health services to be innovative and quickly adapt their health service delivery, including adopting health technology in cancer clinical practice. COVID-19 restrictions forced us to introduce follow-up consultations for many patients via telehealth. At the same time, we adapted an existing Patient Reported Outcome messaging service that linked to the patient’s medical record to allow patients to self-report their health and disease status before their telehealth follow-up consultation. This study aimed to evaluate the feasibility of self-reporting for cancer follow-up care, and determine the patient-clinician level of agreement. Methods Cross-sectional clinical practice study. Patients on radiation oncology follow-up care were sent a text message with a weblink to a survey to self-report their health before their radiation oncologist appointment. Radiation oncologists completed the same set of questions during or within a day of the telehealth follow-up consultation. Descriptive statistics were analysed to evaluate the uptake of self-reporting. Percent agreement and Cohen’s Kappa were used to determine patient-clinician agreement. Results A moderate response rate of 62% was achieved from the 145 patients. There was no difference in the age of patients that were able to complete the assessment. Percent agreement between the patient-reported and the clinician-reported for weight change, appetite, physical performance, side effects was acceptable (>75%). However, percent agreement was moderate for pain and sleep. For most items, Cohen’s Kappa indicated moderate agreement, with pain, side effects, and recurrence being fair. Patients were more likely to report themselves worse than the clinician for all items, except for side effects. Conclusion Patient self-reported health can provide useful information for clinicians to remotely follow-up their patients. This holds promise for future models of follow-up care, particularly for rural and remote patients, and during pandemics and other disasters where clinic attendance is not possible

Development and feasibility testing of PROMPT-Care, an eHealth system for collection and use of patient-reported outcome measures for personalized treatment and care: a study protocol

Background: Patient-reported outcome (PRO) measures have been used widely to screen for depression, anxiety, and symptoms in cancer patients. Computer-based applications that collect patients\u27 responses and transfer them to the treating health professional in real time have the potential to improve patient well-being and cancer outcomes. Objective: This study will test the feasibility and acceptability of a newly developed eHealth system which facilitates PRO data capture from cancer patients, data linkage and retrieval to support clinical decisions and patient self-management, and data retrieval to support ongoing evaluation and innovative research. Methods: The eHealth system is being developed in consultation with 3 overarching content-specific expert advisory groups convened for this project: the clinical advisory group, technical advisory group, and evaluation advisory group. The following work has already been completed during this phase of the study: the Patient-Reported Outcome Measures for Personalized Treatment and Care (PROMPT-Care) eHealth system was developed, patient-reported outcomes were selected (distress, symptoms, unmet needs), algorithms to inform intervention thresholds for clinical and self-management were determined, clinician PRO feedback summary and longitudinal reports were designed, and patient self-management resources were collated. PROsaiq, a custom information technology system, will transfer PRO data in real time into the hospital-based oncology information system to support clinical decision making. The PROMPT-Care system feasibility and acceptability will be assessed through patients completing PROMPT-Care assessments, participating in face-to-face cognitive interviews, and completing evaluation surveys and telephone interviews and oncology staff participating in telephone interviews. Results: Over the course of 3 months, the system will be pilot-tested with up to 50 patients receiving treatment or follow-up care and 6 oncology staff at 2 hospitals in New South Wales, Australia. Data will be collected to determine the accuracy and completeness of data transfer procedures, extent of missing data from participants\u27 assessments, acceptability of the eHealth system and usefulness of the self-management resources (via patient evaluation surveys and interviews), and acceptability and perceived usefulness of real-time PRO reporting (via oncology staff interviews) at the completion of the pilot phase. Conclusions: This research investigates implementation of evidence into real world clinical practice through development of an efficient and user-friendly eHealth system. This study of feasibility and acceptability of the newly developed eHealth system will inform the next stage of larger scale testing and future implementation of the system as part of routine care

Cancer Care Team’s Management of Clinical Alerts Generated by Electronically Collected Patient Reported Outcomes: We Could Do Better

Electronically administered patient-reported outcome measures (ePROMs) are effective digital health tools for informing clinicians about cancer patients’ symptoms and facilitating timely patient-centred care. This paper describes the delivery of healthcare activities supported by the PROMPT-Care model, including ePROMs generated clinical alerts, cancer care team (CCT) response to alerts, and patients’ perceptions of the CCT response and ePROMs system. This mixed-methods study includes cancer patients from four cancer therapy centres in New South Wales, Australia. Quantitative and qualitative data were collected regarding clinical alert activity, CCT response, and patient perceptions of the CCT responses and ePROMs system. Qualitative data were thematically analysed. Of the 328 participants whose care was informed by the digital health tool, 70.8% (n = 233) generated at least one alert during the trial period, with 877 alerts generated in total. Although 43.7% (n = 383) were actioned by the CCT, at least 80% of participants found follow-up CCT phone calls beneficial, with multiple benefits confirmed in interviews. The cancer care delivery arm of the PROMPT-Care trial involving clinical alerts to the CCT was positively perceived by most participants, resulting in a diverse range of benefits. However, further work is required, informed by implementation science, to improve the percentage of actioned clinical alerts