Identifying Core Functions of an Evidence-Based Intervention to Improve Cancer Care Quality in Rural Hospitals

Leveraging inter-organizational networks to scale up a sepsis recovery program: results from an application of the Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI) method

BACKGROUND

Nearly two million adults in the United States are hospitalized with sepsis yearly, with survivors facing complications that result in high rates of hospital readmission and mortality after discharge. We demonstrated improved outcomes following discharge among sepsis survivors who participated in the Sepsis Transition And Recovery (STAR) program; however, important differences among hospitals require STAR's adaptation to facilitate its implementation and ensure its effectiveness in new settings.

PURPOSE

The purpose of this study was to adapt STAR to hospitals with diverse characteristics.

METHODS

We used the Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI) approach. We identified STAR core functions (i.e., effectiveness-driving features) using semi-structured key informant interviews (n = 7). We identified adaptations using semi-structured interviews with clinicians and leaders with expertise and oversight of resources related to transitions of care after sepsis hospitalization (n = 7) from four hospitals that systematically differed from the hospitals in which we originally found STAR to be effective.

RESULTS

Network theory, which proposes that performance improves with more efficient flow of information within and across hospitals, underlays STAR's eleven core functions. Adaptation included specific points-of-contact, communication preferences, and methods for achieving buy-in. We used proposed adaptations to tailor STAR protocols to each hospital.

CONCLUSIONS

We used MODIFI, a state-of-the-science method, to adapt a program that was effective in promoting transition and recovery in sepsis survivors to facilitate its scale-up to diverse hospitals. Future studies will assess STAR's implementation and effectiveness in diverse hospitals.

Closing the Distance: A Qualitative Study to Identify Equitable Innovations for Rural Thyroid Cancer Treatment

BackgroundPatients residing in rural and frontier areas experience worse thyroid cancer outcomes than those in urban areas. This novel qualitative study sought the perspectives of rural surgeons to identify practical measures that could mitigate the disparities in thyroid cancer care between rural and urban contexts.MethodsWe contacted general and head and neck surgeons at all of California's Critical Access Hospitals (n = 35), which are remote, rural hospitals, and requested self-referral to our study through the American College of Surgeons. We performed semi-structured qualitative interviews with surgeons at rural hospitals to understand the assets and vulnerabilities of rural hospitals in providing the highest quality care to patients with thyroid cancer. Responses were coded and analyzed using mixed-methods qualitative analysis methodology.ResultsRural surgeons (n = 13) from a geographically diverse sample of states and regions (AK, AR, CA, NE, NC, NM, TX, UT, WY, and Newfoundland) participated. All initially trained in general surgery; 46% had fellowship training (15% in endocrine surgery) and performed a median of 8.5 thyroidectomies annually.Rural surgeons from all training backgrounds felt adequately trained to treat thyroid cancer and reported a strong desire to provide comprehensive thyroid cancer care. Most reported patients' strong preference to be treated near home. Key challenges to local, comprehensive thyroid cancer care included limited or no access to medical endocrinology, lack of continuing education on thyroid cancer management, and professional isolation in decision-making. Interviewed rural surgeons identified connections with university health systems, expert colleagues, and telemedicine consultations as valuable assets in treating thyroid cancer in geographically isolated hospitals.DiscussionThis study identified key challenges and clear avenues for interventions in treating rural thyroid cancer patients. Interviewed rural surgeons specifically suggest improving access to endocrinology specialists, developing educational initiatives on thyroid cancer management, and fostering connections and collaborations with urban colleagues to reduce professional isolation.

Organization Theory for Implementation Science (OTIS): reflections and recommendations

Organizations exert influence on the implementation of evidence-based practices and other innovations that are independent of the influence of organizations' individual constituents. Despite their influence, nuanced explanations of organizations' influence remain limited in implementation science. Organization theories are uniquely suited to offer insights and explain organizational influences on implementation. In this paper, we describe the efforts of the Cancer Prevention and Control Research Network's (CPCRN) Organization Theory for Implementation Science (OTIS) workgroup to equip implementation scientists with theory-guided understanding of organizational influences on implementation. We provide a set of recommendations for future efforts to enhance implementation through the use of organization theories and OTIS tools.

Leveraging public health cancer surveillance capacity to develop and support a rural cancer network

Introduction

As the rural-urban cancer mortality gap widens, centering care around the needs of rural patients presents an opportunity to advance equity. One barrier to delivering patient-centered care at rural hospitals stems from limited analytic capacity to leverage data and monitor patient outcomes. This case study describes the experience of a public health cancer surveillance system aiming to fill this gap within the context of a rural cancer network.

Methods

To support the implementation of a novel network model intervention in Iowa, the Iowa Cancer Registry began generating hospital-specific and catchment area reports. Then, the Iowa Cancer Registry supported adapting the network model to fit the context of Iowa's cancer care delivery system by performing data monitoring and reporting functions. Informed by a gap analysis, the Iowa Cancer Registry then identified which quality accreditation standards could be achieved with public health surveillance data and analytic support.

Results

The network intervention in Iowa supported 5 rural cancer centers across the state, each concurrently pursuing quality accreditation standards. The Iowa Cancer Registry's hospital and catchment-specific reports illuminated the cancer burden and needs of rural cancer centers within the network. Our team identified 19 (of the 36 total) quality standards that can be supported by public health surveillance functions typically performed by the registry. These standards encompassed data-driven quality improvement, patient monitoring, and reporting guideline-concordant care standards.

Conclusions

As rural hospitals continue to face resource constraints, multisectoral efforts informed by data from centralized public health surveillance systems can promote quality improvement initiatives across rural communities. While our work remains preliminary, we predict that analytic support provided by the Iowa Cancer Registry will enable the rural network hospitals to focus their capacity toward developing the infrastructure necessary to deliver high-quality care and serve the unique needs of rural cancer patients.

Rural comprehensive cancer care: Qualitative analysis of current challenges and opportunities

PURPOSE

While limited resources can make high-quality, comprehensive, coordinated cancer care provision challenging in rural settings, rural cancer patients often rely on local hospitals for care. To develop resources and strategies to support high-quality local cancer care, it is critical to understand the current experiences of rural cancer care physicians, including perceived strengths and challenges of providing cancer care in rural areas.  METHODS: Semi-structured interviews were conducted with 13 cancer providers associated with all 12 non-metropolitan/rural Iowa hospitals that diagnose or treat >100 cancer patients annually. Iterative thematic analysis was conducted to develop domains.

FINDINGS

Participants identified geographic proximity and sense of community as strengths of local care. They described decision-making processes and challenges related to referring patients to larger centers for complex procedures, including a lack of dedicated navigators to facilitate and track transfers between institutions and occasional lack of respect from academic physicians. Participants reported a desire for strengthening collaborations with larger urban/academic cancer centers, including access to educational opportunities, shared resources and strategies to collect and monitor data on quality, and clinical trials.

CONCLUSIONS

Rural cancer care providers are dedicated to providing high-quality care close to home for their patients and would welcome opportunities to increase collaboration with larger centers to improve coordination and comprehensiveness of care, collect and monitor data on quality of care, and access continuing education opportunities. Further research is needed to develop implementation approaches that will extend resources, services, and expertise to rural providers to facilitate high-quality cancer care for all cancer patients.

Factors Influencing Implementation of the Commission on Cancer's Breast Synoptic Operative Report (Alliance A20_Pilot9)

BACKGROUND

The technical aspects of cancer surgery have a significant impact on patient outcomes. To monitor surgical quality, in 2020, the Commission on Cancer (CoC) revised its accreditation standards for cancer surgery and introduced the synoptic operative reports (SORs). The standardization of SORs holds promise, but successful implementation requires strategies to address key implementation barriers. This study aimed to identify the barriers and facilitators to implementing breast SOR within diverse CoC-accredited programs.

METHODS

In-depth semi-structured interviews were conducted with 31 health care professionals across diverse CoC-accredited sites. The study used two comprehensive implementation frameworks to guide data collection and analysis.

RESULTS

Successful SOR implementation was impeded by disrupted workflows, surgeon resistance to change, low prioritization of resources, and poor flow of information despite CoC's positive reputation. Participants often lacked understanding of the requirements and timeline for breast SOR and were heavily influenced by prior experiences with templates and SOR champion relationships. The perceived lack of monetary benefits (to obtaining CoC accreditation) together with the significant information technology (IT) resource requirements tempered some of the enthusiasm. Additionally, resource constraints and the redirection of personnel during the COVID-19 pandemic were noted as hurdles.

CONCLUSIONS

Surgeon behavior and workflow change, IT and personnel resources, and communication and networking strategies influenced SOR implementation. During early implementation and the implementation planning phase, the primary focus was on achieving buy-in and initiating successful roll-out rather than effective use or sustainment. These findings have implications for enhancing standardization of surgical cancer care and guidance of future strategies to optimize implementation of CoC accreditation standards.

Hospital Accreditation Status and Treatment Differences Among Black Patients With Colon Cancer

Importance

Hospital-level factors, such as hospital type or volume, have been demonstrated to play a role in treatment disparities for Black patients with cancer. However, data evaluating the association of hospital accreditation status with differences in treatment among Black patients with cancer are lacking.

Objective

To evaluate the association of Commission on Cancer (CoC) hospital accreditation status with receipt of guideline-concordant care and mortality among non-Hispanic Black patients with colon cancer.

Design, Setting, and Participants

This population-based cohort study used the National Program of Cancer Registries, which is a multicenter database with data from all 50 states and the District of Columbia, and covers 97% of the cancer population in the US. The participants included non-Hispanic Black patients aged 18 years or older diagnosed with colon cancer between January 1, 2018, and December 31, 2020. Race and ethnicity were abstracted from medical records as recorded by health care facilities and practitioners. The data were analyzed from December 7, 2023, to January 17, 2024.

Exposure

CoC hospital accreditation.

Main Outcome and Measures

Guideline-concordant care was defined as adequate lymphadenectomy during surgery for patients with stages I to III disease or chemotherapy administration for patients with stage III disease. Multivariable logistic regression models investigated associations with receipt of guideline-concordant care and Cox proportional hazards regression models assessed associations with 3-year cancer-specific mortality.

Results

Of 17 249 non-Hispanic Black patients with colon cancer (mean [SD] age, 64.8 [12.8] years; 8724 females [50.6%]), 12 756 (74.0%; mean [SD] age, 64.7 [12.8] years) were treated at a CoC-accredited hospital and 4493 (26.0%; mean [SD] age, 65.1 [12.5] years) at a non-CoC-accredited hospital. Patients treated at CoC-accredited hospitals compared with those treated at non-CoC-accredited hospitals had higher odds of receiving guideline-concordant lymphadenectomy (adjusted odds ratio [AOR], 1.89; 95% CI, 1.69-2.11) and chemotherapy (AOR, 2.31; 95% CI, 1.97-2.72). Treatment at CoC-accredited hospitals was associated with lower cancer-specific mortality for patients with stages I to III disease who received surgery (adjusted hazard ratio [AHR], 0.87; 95% CI, 0.76-0.98) and for patients with stage III disease eligible for chemotherapy (AHR, 0.75; 95% CI, 0.59-0.96).

Conclusions and Relevance

In this cohort study of non-Hispanic Black patients with colon cancer, patients treated at CoC-accredited hospitals compared with those treated at non-CoC-accredited hospitals were more likely to receive guideline-concordant care and have lower mortality risk. These findings suggest that increasing access to high-quality guideline-concordant care at CoC-accredited hospitals may reduce variations in cancer treatment and outcomes for underserved populations.

Reducing uncertainty in evidence-based health policy by integrating empirical and theoretical evidence: An EbM+theory approach

BACKGROUND

To reduce their decisional uncertainty, health policy decision-makers rely more often on experts or their intuition than on evidence-based knowledge, especially in times of urgency. However, this practice is unacceptable from an evidence-based medicine (EbM) perspective. Therefore, in fast-changing and complex situations, we need an approach that delivers recommendations that serve decision-makers' needs for urgent, sound and uncertainty-reducing decisions based on the principles of EbM.

AIMS

The aim of this paper is to propose an approach that serves this need by enriching EbM with theory.

MATERIALS AND METHODS

We call this the EbM+theory approach, which integrates empirical and theoretical evidence in a context-sensitive way to reduce intervention and implementation uncertainty.

RESULTS

Within this framework, we propose two distinct roadmaps to decrease intervention and implementation uncertainty: one for simple and the other for complex interventions. As part of the roadmap, we present a three-step approach: applying theory (step 1), conducting mechanistic studies (EbM+; step 2) and conducting experiments (EbM; step 3).

DISCUSSION

This paper is a plea for integrating empirical and theoretical knowledge by combining EbM, EbM+ and theoretical knowledge in a common procedural framework that allows flexibility even in dynamic times. A further aim is to stimulate a discussion on using theories in health sciences, health policy, and implementation.

CONCLUSION

The main implications are that scientists and health politicians - the two main target groups of this paper-should receive more training in theoretical thinking; moreover, regulatory agencies like NICE may think about the usefulness of integrating elements of the EbM+theory approach into their considerations.

Toward a more comprehensive understanding of organizational influences on implementation: the organization theory for implementation science framework

Introduction

Implementation is influenced by factors beyond individual clinical settings. Nevertheless, implementation research often focuses on factors related to individual providers and practices, potentially due to limitations of available frameworks. Extant frameworks do not adequately capture the myriad organizational influences on implementation. Organization theories capture diverse organizational influences but remain underused in implementation science. To advance their use among implementation scientists, we distilled 70 constructs from nine organization theories identified in our previous work into theoretical domains in the Organization Theory for Implementation Science (OTIS) framework.

Methods

The process of distilling organization theory constructs into domains involved concept mapping and iterative consensus-building. First, we recruited organization and implementation scientists to participate in an online concept mapping exercise in which they sorted organization theory constructs into domains representing similar theoretical concepts. Multidimensional scaling and hierarchical cluster analyses were used to produce visual representations (clusters) of the relationships among constructs in concept maps. Second, to interpret concept maps, we engaged members of the Cancer Prevention and Control Research Network (CPCRN) OTIS workgroup in consensus-building discussions.

Results

Twenty-four experts participated in concept mapping. Based on resulting construct groupings' coherence, OTIS workgroup members selected the 10-cluster solution (from options of 7-13 clusters) and then reorganized clusters in consensus-building discussions to increase coherence. This process yielded six final OTIS domains: organizational characteristics (e.g., size; age); governance and operations (e.g., organizational and social subsystems); tasks and processes (e.g., technology cycles; excess capacity); knowledge and learning (e.g., tacit knowledge; sense making); characteristics of a population of organizations (e.g., isomorphism; selection pressure); and interorganizational relationships (e.g., dominance; interdependence).

Discussion

Organizational influences on implementation are poorly understood, in part due to the limitations of extant frameworks. To improve understanding of organizational influences on implementation, we distilled 70 constructs from nine organization theories into six domains. Applications of the OTIS framework will enhance understanding of organizational influences on implementation, promote theory-driven strategies for organizational change, improve understanding of mechanisms underlying relationships between OTIS constructs and implementation, and allow for framework refinement. Next steps include testing the OTIS framework in implementation research and adapting it for use among policymakers and practitioners.

Core functions of a financial navigation intervention: An in-depth assessment of the Lessening the Impact of Financial Toxicity (LIFT) intervention to inform adaptation and scale-up in diverse oncology care settings

Background

Lessening the Impact of Financial Toxicity (LIFT) is an intervention designed to address financial toxicity (FT) and improve cancer care access and outcomes through financial navigation (FN). FN identifies patients at risk for FT, assesses eligibility for financial support, and develops strategies to cope with those costs. LIFT successfully reduced FT and improved care access in a preliminary study among patients with high levels of FT in a single large academic cancer center. Adapting LIFT requires distinguishing between core functions (components that are key to its implementation and effectiveness) and forms (specific activities that carry out core functions). Our objective was to complete the first stage of adaptation, identifying LIFT core functions.

Methods

We reviewed LIFT's protocol and internal standard-operating procedures. We then conducted 45-90 min in-depth interviews, using Kirk's method of identifying core functions, with key LIFT staff (N = 8), including the principal investigators. Interviews focused on participant roles and intervention implementation. Recorded interviews were transcribed verbatim. Using ATLAS.ti and a codebook based on the Model for Adaptation Design and Impact, we coded interview transcripts. Through thematic analysis, we then identified themes related to LIFT's intervention and implementation core functions. Two report back sessions with interview participants were incorporated to further refine themes.

Results

Six intervention core functions (i.e., what makes LIFT effective) and five implementation core functions (i.e., what facilitated LIFT's implementation) were identified to be sufficient to reduce FT. Intervention core functions included systematically cataloging knowledge and tracking patient-specific information related to eligibility criteria for FT relief. Repeat contacts between the financial navigator and participant created an ongoing relationship, removing common barriers to accessing resources. Implementation core functions included having engaged sites with the resources and willingness necessary to implement FN. Developing navigators' capabilities to implement LIFT-through training, an established case management system, and connections to peer navigators-were also identified as implementation core functions.

Conclusion

This study adds to the growing evidence on FN by characterizing intervention and implementation core functions, a critical step toward promoting LIFT's implementation and effectiveness.