1
|
Brade A, Jao K, Yu S, Cheema P, Doucette S, Christofides A, Schellenberg D. A Canadian Perspective on the Challenges for Delivery of Curative-Intent Therapy in Stage III Unresectable Non-Small Cell Lung Cancer. ACTA ACUST UNITED AC 2021; 28:1618-1629. [PMID: 33923355 PMCID: PMC8161772 DOI: 10.3390/curroncol28030151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 11/16/2022]
Abstract
Stage III non-small cell lung cancer (NSCLC) comprises a highly heterogenous group of patients with regards to patient fitness and tumour size and distribution, resulting in a wide range of treatment goals and therapy options. Curative-intent multimodality treatment should be considered in all patients with stage III NSCLC. For patients with unresectable disease who are fit, have adequate lung function, and have a disease that can be encompassed within a radical radiation volume, concurrent chemoradiation therapy (cCRT) is the standard of care and can produce cure rates of 20–30%. Recently, consolidation immunotherapy with durvalumab has been recognized as the standard of care following cCRT based on significant improvement rates in overall survival at 4 years. The large heterogeneity of the stage III NSCLC population, along with the need for extensive staging procedures, multidisciplinary care, intensive cCRT, and now consolidation therapy makes the delivery of timely and optimal treatment for these patients complex. Several logistical, communication, and education factors hinder the delivery of guideline-recommended care to patients with stage III unresectable NSCLC. This commentary discusses the potential challenges patients may encounter at different points along their care pathway that can interfere with delivery of curative-intent therapy and suggests strategies for improving care delivery.
Collapse
Affiliation(s)
- Anthony Brade
- Department of Radiation Oncology, Peel Regional Cancer Centre, Mississauga, ON L5M 2N1, Canada
- Correspondence:
| | - Kevin Jao
- Department of Hematology and Oncology, Hôpital du Sacré-Coeur de Montréal, Montreal, QC H4J 1C5, Canada;
| | - Simon Yu
- Department of Medicine, Burnaby Hospital Cancer Centre, Burnaby, BC V5G 2X6, Canada;
| | - Parneet Cheema
- Department of Medicine, Division of Medical Oncology, University of Toronto, Toronto, ON M5S 3H2, Canada;
- William Osler Health System, Brampton, ON L6R 3J7, Canada
| | - Sarah Doucette
- Senior Medical Writer, IMPACT Medicom Inc., Toronto, ON M6S 3K2, Canada; (S.D.); (A.C.)
| | - Anna Christofides
- Senior Medical Writer, IMPACT Medicom Inc., Toronto, ON M6S 3K2, Canada; (S.D.); (A.C.)
| | - Devin Schellenberg
- Department of Radiation Oncology, BC Cancer Agency, Surrey, BC V2V 1Z2, Canada;
| |
Collapse
|
2
|
Habbous S, Khan Y, Langer DL, Kaan M, Green B, Forster K, Darling G, Holloway CMB. The effect of diagnostic assessment programs on the diagnosis and treatment of patients with lung cancer in Ontario, Canada. Ann Thorac Med 2021; 16:81-101. [PMID: 33680129 PMCID: PMC7908893 DOI: 10.4103/atm.atm_283_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/26/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Diagnostic assessment programs (DAPs) were implemented in Ontario, Canada, to improve the efficiency of the lung cancer care continuum. We compared the efficiency and effectiveness of care provided to patients in DAPs relative to usual care (non-DAPs). METHODS Lung cancer patients diagnosed between 2014 and 2016 were identified from the Ontario Cancer Registry. Using administrative databases, we identified various health-care encounters 6 months before diagnosis until the start of treatment and compared utilization patterns, timing, and overall survival between DAP and non-DAP patients. RESULTS DAP patients were younger (P < 0.0001), had fewer comorbidities (P = 0.0006), and were more likely to have early-stage disease (36% vs. 25%) than non-DAP patients. Although DAP patients had a similar time until diagnosis as non-DAP patients, the time until treatment was 8.5 days shorter for DAP patients. DAP patients were more likely to receive diagnostic tests and specialist consultations and less likely to have duplicate chest imaging. DAP patients were more likely to receive brain imaging. Among early-stage lung cancers, brain imaging was high (74% for DAP and 67% for non-DAP), exceeding guideline recommendations. After adjustment for clinical and demographic factors, DAP patients had better overall survival than non-DAP patients (hazard ratio [HR]: 0.79 [0.76-0.82]), but this benefit was lost after adjusting for emergency presentation (HR: 0.96 [0.92-1.00]). A longer time until treatment was associated with better overall survival. CONCLUSION DAPs provided earlier treatment and better access to care, potentially improving survival. Quality improvement opportunities include reducing unnecessary or duplicate testing and characterizing patients who are diagnosed emergently.
Collapse
Affiliation(s)
- Steven Habbous
- Clinical Programs and Quality Initiatives, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Yasir Khan
- Clinical Programs and Quality Initiatives, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Deanna L Langer
- Clinical Programs and Quality Initiatives, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Melissa Kaan
- Clinical Programs and Quality Initiatives, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Bo Green
- Clinical Programs and Quality Initiatives, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Katharina Forster
- Clinical Programs and Quality Initiatives, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Gail Darling
- Clinical Programs and Quality Initiatives, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Claire M B Holloway
- Clinical Programs and Quality Initiatives, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| |
Collapse
|
3
|
Lafferty M, Fauer A, Wright N, Manojlovich M, Friese CR. Causes and Consequences of Chemotherapy Delays in Ambulatory Oncology Practices: A Multisite Qualitative Study. Oncol Nurs Forum 2020; 47:417-427. [PMID: 32555555 PMCID: PMC7310592 DOI: 10.1188/20.onf.417-427] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE In oncology, chemotherapy treatment delays potentially jeopardize patient safety and impede progress toward disease remission. The purpose of this study was to examine the causes and consequences of chemotherapy treatment delays and possible solutions to improve quality of care. PARTICIPANTS & SETTING The current authors selected a purposive sample of eight ambulatory oncology practices for ethnographic site visits, which lasted five days each. METHODOLOGIC APPROACH The authors conducted 290 observation hours, including clinician shadowing, and 46 semistructured interviews with clinicians (oncology nurses, physicians, and advanced practice providers). Deductive and inductive thematic analysis was performed on all data. FINDINGS The authors identified four primary themes from the analysis that affect delays. IMPLICATIONS FOR NURSING Future investigations should examine nurses' communication practices in the context of timely chemotherapy administration because communication and documentation technologies within healthcare settings continuously evolve.
Collapse
Affiliation(s)
| | | | | | | | - Christopher R Friese
- University of Michigan School of Nursing and University of Michigan Rogel Cancer Center
| |
Collapse
|
4
|
Linford G, Egan R, Coderre-Ball A, Dalgarno N, Stone CJL, Robinson A, Robinson D, Wakeham S, Digby GC. Patient and physician perceptions of lung cancer care in a multidisciplinary clinic model. ACTA ACUST UNITED AC 2020; 27:e9-e19. [PMID: 32218663 DOI: 10.3747/co.27.5499] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Lung cancer (lc) is a complex disease requiring coordination of multiple health care professionals. A recently implemented lc multidisciplinary clinic (mdc) at Kingston Health Sciences Centre, an academic tertiary care hospital, improved timeliness of oncology assessment and treatment. This study describes patient, caregiver, and physician experiences in the mdc. Methods We qualitatively studied patient, caregiver, and physician experiences in a traditional siloed care model and in the mdc model. We used purposive sampling to conduct semi-structured interviews with patients and caregivers who received care in one of the models and with physicians who worked in both models. Thematic design by open coding in the ATLAS.ti software application (ATLAS.ti Scientific Software Development, Berlin, Germany) was used to analyze the data. Results Participation by 6 of 72 identified patients from the traditional model and 6 of 40 identified patients from the mdc model was obtained. Of 9 physicians who provided care in both models, 8 were interviewed (2 respirologists, 2 medical oncologists, 4 radiation oncologists). Four themes emerged: communication and collaboration, efficiency, quality of care, and effect on patient outcomes. Patients in both models had positive impressions of their care. Patients in the mdc frequently reported convenience and a positive effect of family presence at appointments. Physicians reported that the mdc improved communication and collegiality, clinic efficiency, patient outcomes and satisfaction, and consistency of information provided to patients. Physicians identified lack of clinic space as an area for mdc improvement. Conclusions This qualitative study found that a lc mdc facilitated patient communication and physician collaboration, improved quality of care, and had a perceived positive effect on patient outcomes.
Collapse
Affiliation(s)
- G Linford
- Department of Oncology, Cancer Centre of Southeastern Ontario
| | - R Egan
- School of Nursing, Queen's University
| | - A Coderre-Ball
- Office of Professional Development and Educational Scholarship, Faculty of Health Sciences, Queen's University
| | - N Dalgarno
- Office of Professional Development and Educational Scholarship, Faculty of Health Sciences, Queen's University
| | - C J L Stone
- Department of Medicine, Kingston Health Sciences Centre
| | - A Robinson
- Department of Oncology, Cancer Centre of Southeastern Ontario
| | | | - S Wakeham
- School of Medicine, Queen's University
| | - G C Digby
- Department of Oncology, Cancer Centre of Southeastern Ontario.,Department of Medicine, Kingston Health Sciences Centre.,Division of Respirology, Kingston Health Sciences Centre, Queen's University, Kingston, ON
| |
Collapse
|
5
|
Adizie JB, Khakwani A, Beckett P, Hubbard R, Navani N, Harden SV, Woolhouse I. Impact of organisation and specialist service delivery on lung cancer outcomes. Thorax 2019; 74:546-550. [PMID: 30661021 DOI: 10.1136/thoraxjnl-2018-212588] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 12/21/2018] [Accepted: 01/02/2019] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Data from the National Lung Cancer Audit (NLCA) often show variation in outcomes between lung cancer units which are not entirely explained by case mix. We explore the association between the organisation of services and patient outcome. METHODS Details of service provision were collected via an electronic survey in June 2017. An overall organisational score derived from eleven key service factors from national lung cancer commissioning guidance was calculated for each organisation. The results for each hospital were linked to their patient outcome results from the 2015 NLCA cases. Multivariate logistic regression analysis was used to link the organisational score to patient outcomes. RESULTS Lung cancer unit organisational audit scores varied from 0 to 11. Thirty-eight (29%) units had a score of 0-4, 64 (50%) had a score of 5-7 and 27 (21%) had a score of 8-11. Multivariate regression analysis revealed that, compared with an organisational score of 0-4, patients seen at units with a score of 8-11 had higher 1-year survival (adjusted OR (95% CI)=2.30 (1.04 to 5.08), p<0.001), higher curative-intent treatment rate (adjusted OR (95% CI)=1.62 (1.26 to 2.09), p<0.001) and greater likelihood of receiving treatment within 62 days (adjusted OR (95% CI)=1.49 (1.20 to 1.86), p<0.001). CONCLUSION National variation in the provision of services and workforce remain. We provide evidence that adherence to the national lung commissioning guidance has the potential to improve patient outcomes within the current service structure.
Collapse
Affiliation(s)
- Jana Bhavani Adizie
- Department of Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK.,Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Aamir Khakwani
- Care Quality Improvement Department, Royal College of Physicians, London, UK
| | - Paul Beckett
- Care Quality Improvement Department, Royal College of Physicians, London, UK
| | - Richard Hubbard
- Care Quality Improvement Department, Royal College of Physicians, London, UK
| | - Neal Navani
- Care Quality Improvement Department, Royal College of Physicians, London, UK
| | - Susan V Harden
- Care Quality Improvement Department, Royal College of Physicians, London, UK
| | - Ian Woolhouse
- Department of Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK.,Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Care Quality Improvement Department, Royal College of Physicians, London, UK
| |
Collapse
|
6
|
Desveaux L, Gagliardi AR. Comparing the application of two theoretical frameworks to describe determinants of adverse medical device event reporting: secondary analysis of qualitative interview data. BMC Health Serv Res 2018; 18:402. [PMID: 29866152 PMCID: PMC5987566 DOI: 10.1186/s12913-018-3251-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 05/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Post-market surveillance of medical devices is reliant on physician reporting of adverse medical device events (AMDEs). Few studies have examined factors that influence whether and how physicians report AMDEs, an essential step in the development of behaviour change interventions. This study was a secondary analysis comparing application of the Theoretical Domains Framework (TDF) and the Tailored Implementation for Chronic Diseases (TICD) framework to identify potential behaviour change interventions that correspond to determinants of AMDE reporting. METHODS A previous study involving qualitative interviews with Canadian physicians that implant medical devices identified themes reflecting AMDE reporting determinants. In this secondary analysis, themes that emerged from the primary analysis were independently mapped to the TDF and TICD. Determinants and corresponding intervention options arising from both frameworks (and both mappers) were compared. RESULTS Both theoretical frameworks were useful for identifying interventions corresponding to behavioural determinants of AMDE reporting. Information or education strategies that provide evidence about AMDEs, and audit and feedback of AMDE data were identified as interventions to target the theme of physician beliefs; improving information systems, and reminder cues, prompts and awards were identified as interventions to address determinants arising from the organization or systems themes; and modifying financial/non-financial incentives and sharing data on outcomes associated with AMDEs were identified as interventions to target device market themes. Numerous operational challenges were encountered in the application of both frameworks including a lack of clarity about how directly relevant to themes the domains/determinants should be, how many domains/determinants to select, if and how to resolve discrepancies across multiple mappers, and how to choose interventions from among the large number associated with selected domains/determinants. CONCLUSIONS Given discrepancies in mapping themes to determinants/domains and the resulting interventions offered by the two frameworks, uncertainty remains about how to choose interventions that best match behavioural determinants in a given context. Further research is needed to provide more nuanced guidance on the application of TDF and TICD for a broader audience, which is likely to increase the utility and uptake of these frameworks in practice.
Collapse
|