The association between patients' perceived continuity of care and beliefs about oral anticancer treatment

Telehomecare Monitoring for Patients Receiving Anticancer Oral Therapy: Protocol for a Mixed Methods Evaluability Study

BACKGROUND

Telehomecare monitoring (TM) in patients with cancer is a complex intervention. Research shows variations in the benefits and challenges TM brings to equitable access to care, the therapeutic relationship, self-management, and practice transformation. Further investigation into these variations factors will improve implementation processes and produce effective outcomes.

OBJECTIVE

This study aims to concurrently analyze implementation and evaluate the effectiveness of TM for patients receiving anticancer oral therapy. The objectives are to (1) contextualize how and why TM is implemented according to (a) site characteristics, (b) team characteristics, and (c) characteristics of patients receiving anticancer oral therapy; (2) assess TM effectiveness for recording electronic patient-reported outcome measures (ePROMs) and patient-reported experience measures (ePREMs) according to the site, implementation process, and patient characteristics; (3) describe the acceptability and feasibility of TM from the perspectives of the people directly or indirectly involved and provide evidence-based actionable guidance in anticipation of provincewide implementation.

METHODS

This type II hybrid effectiveness-implementation study uses a concurrent mixed methods design. Evaluability assessment is integrated into an emerging practice in 3 participating sites to enable the evaluation of implementation strategies on TM clinical outcomes. Quantitative data for ePROMs and ePREMs will be collected using validated oncology questionnaire. Descriptive statistics and repeated measures using multiple linear mixed models and generalized estimating equations analyses will be undertaken alongside interpretive descriptive coding of qualitative data. Qualitative data will be gathered from key informants guided by the RE-AIM (reach, efficacy, adoption, implementation, maintenance) framework and its extension, PRISM (practical robust implementation and sustainability model). The concurrent approach allows results at multiple stages of this study to be integrated iteratively. The methodological choice aims to provide real-world data that are rigorous, rapidly usable in practice, and transferable to other settings.

RESULTS

Questionnaires were pretested and the technological platform was codeveloped with members of the cancer care team and patients. Preparatory work was carried out to configure the TM platform and activate coordinating mechanisms between members of the cancer care team, patients, information technology experts, and the research team. A steering committee with 3 working groups was established to oversee the technological, clinical, and evaluation aspects of this study. Recruitment of patients for ePROMs started in February 2024, and data collection is expected to continue until March 2025. Interviews with members of the cancer care team began in November 2024. Full analysis should be completed by September 2025.

CONCLUSIONS

This study will clarify how, why, for whom, and under what conditions TM can complement current care models. Our evaluability assessment will help to address implementation complexities and better understand intervention-to-practice operationalization so that implementation might be adapted to contextual factors without potentially harmful or inequitable impacts on patients.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/63099.

Provider- and patient-level predictors of oral anticancer agent initiation and adherence in patients with metastatic renal cell carcinoma

Background

Improving oral anticancer agent (OAA) initiation and adherence is the important quality‐of‐care issues, particularly since one fourth of anticancer agents being developed will be administered orally. Our objective was to identify provider‐ and patient‐level characteristics associated with OAA initiation and adherence among individuals with metastatic renal cell carcinoma (mRCC).

Methods

We used state cancer registry data linked to multi‐payer claims data to identify patients with mRCC diagnosed in 2004–2015. Provider data were obtained from North Carolina Health Professions Data System and the National Plan & Provider Enumeration System. We estimated risk ratios (RRs) and corresponding 95% confidence limits (CLs) using modified Poisson regression to evaluate factors associated with OAA initiation and adherence.

Results

Among the 207 (out of 687) patients who initiated an OAA following mRCC diagnosis and survived 90 days, median proportion of days covered was 0.91. Patients with a modal provider specializing in hematology/medical oncology were much more likely to initiate OAAs than those seen by other specialties. Additionally, patients with a female provider were more likely to initiate OAAs than those with a male provider. Compared to patients treated by providers practicing in both urban and rural areas, patients with providers practicing solely in urban areas were more likely to initiate OAAs, after controlling for patient‐level factors (RR = 1.37; 95% CL: 1.09–1.73). Medicare patients were less likely to be adherent than those with private insurance (RR = 0.61; 95% CL: 0.42–0.87).

Conclusions

Our results suggest that provider‐ and patient‐level factors influence OAA initiation in patients with mRCC but only insurance type was associated with adherence.

Patients' Perceived Continuity of Care and Adherence to Oral Anticancer Therapy: a Prospective Cohort Mediation Study

BACKGROUND

Oral anticancer therapy (OACT) poses adherence-related challenges to patients while generating a setting in which both primary care physicians (PCPs) and oncologists are involved in the active treatment of cancer. Continuity of care (COC) was shown to be associated with medication adherence. While maintaining COC is a central role of the PCP, how this affects continuity with oncologists, and jointly affects OACT adherence, is yet unknown.

OBJECTIVES

To explore how aspects of COC act together to promote OACT adherence. Specifically, to examine whether better personal continuity with the PCP leads to better personal continuity with the oncologist, which together lead to better cross-boundary continuity between the oncologist and the PCP, jointly leading to good adherence to OACT.

DESIGN AND SETTING

A prospective cohort study conducted in five oncology centers in Israel. A bootstrapping method was used to test the serial mediation model.

PARTICIPANTS

Adult patients (age > 18 years) receiving a first OACT prescription (n = 119) were followed for 120 days.

MAIN MEASURES

The Nijmegen Continuity Questionnaire was used to assess patients' perceived personal and cross-boundary continuity. The medication possession ratio was used to measure adherence.

KEY RESULTS

Better personal continuity with the PCP was associated with better personal continuity with the oncologist (B = 0.35, p < 0.001), which was associated with better cross-boundary continuity (B = 0.33, p < 0.001), which, in turn, was associated with good adherence to OACT (B = 0.46, p = 0.03). Additionally, the indirect effect of personal continuity with the PCP on adherence to OACT through the mediation of personal continuity with the oncologist and cross-boundary continuity was found to be statistically significant (B = 0.053, 95% CI 0.0006-0.17).

CONCLUSIONS

In a system where the PCP is the case manager, cancer patients' perceived personal continuity with the PCP has an essential role for initiating a sequence of care delivery events that positively affect OACT adherence.

Effects of continuity of care on the postradiotherapy survival of working-age patients with oral cavity cancer: A nationwide population-based cohort study in Taiwan

Objectives

Cancer of the oral cavity, a well-known global health concern, remains one of most common causes of cancer mortality. Continuity of care (COC), a measurement of the extent to which an individual patient receives care from a given provider over a specified period of time, can help cancer survivors process their experiences of dealing with the illness and recuperation; however, limited research has focused on the survival rate of working-age patients with oral cancer.

Methods

A total of 14,240 working-age patients (20 <age ≤65 years) with oral cavity cancer treated with radiotherapy (RT) during 2000–2013 were included in this study from a registry of patients with catastrophic illnesses maintained by the Taiwan National Health Insurance Research Database. We evaluated the effects of the Continuity of Care Index (COCI) proposed by Bice and Boxerman, sociodemographic factors, and comorbidities on the survival rate. This study categorized COC into three groups—low (COCI < 0.23), intermediate (COCI = 0.23–0.37), and high (COCI ≥ 0.38)—according to the distribution of scores in our sample. A multivariate Cox proportional hazards regression model was used to determine the demographic factors and comorbidities associated with the survival rate.

Results

Among all the relevant variables, low COCI, male sex, low socioeconomic status, no receipt of prior dental treatment before RT, residence outside northern Taiwan, chemotherapy receipt, and a history of diabetes increased the risk of mortality. Pre-RT dental evaluation and management was significantly associated with reduced post-RT mortality (adjusted hazard ratio [aHR] = 0.767, 95% confidence interval [CI] = 0.729–0.806, p < 0.001). Compared with patients with a high COCI, those with a low COCI exhibited an increased risk of mortality (aHR = 1.170, 95% CI = 1.093–1.252, p < 0.001). The mortality risk in the intermediate COC group was significantly higher than that in the high COC group (aHR = 1.194, 95% CI = 1.127–1.266, p < 0.001). To balance the distribution of the potential risk factors, propensity-score matching was used for the high COC (COCI > 0.38) and non-high COC (COCI ≤ 0.38) groups. After propensity-score matching, the mortality risk in the low and intermediate COC groups was also found to be significantly higher than that in the high COC group (aHR = 1.178, 95% CI = 1.074–1.292, p < 0.001 and aHR = 1.189, 95% CI = 1.107–1.277, p = 0.001, respectively).

Conclusions

In Taiwan, COC and prior dental treatment before RT significantly affected the survival rate of working-age patients with oral cancer. This result merits policymakers’ attention.