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Ashley L, Surr C, Kelley R, Price M, Griffiths AW, Fowler NR, Giza DE, Neal RD, Martin C, Hopkinson JB, O'Donovan A, Dale W, Koczwara B, Spencer K, Wyld L. Cancer care for people with dementia: Literature overview and recommendations for practice and research. CA Cancer J Clin 2022; 73:320-338. [PMID: 36512303 DOI: 10.3322/caac.21767] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/02/2022] [Accepted: 11/01/2022] [Indexed: 12/14/2022] Open
Abstract
As many countries experience population aging, patients with cancer are becoming older and have more preexisting comorbidities, which include prevalent, age-related, chronic conditions such as dementia. People living with dementia (PLWD) are vulnerable to health disparities, and dementia has high potential to complicate and adversely affect care and outcomes across the cancer trajectory. This report offers an overview of dementia and its prevalence among patients with cancer and a summary of the research literature examining cancer care for PLWD. The reviewed research indicates that PLWD are more likely to have cancer diagnosed at an advanced stage, receive no or less extensive cancer treatment, and have poorer survival after a cancer diagnosis. These cancer disparities do not necessarily signify inappropriately later diagnosis or lower treatment of people with dementia as a group, and they are arguably less feasible and appropriate targets for care optimization. The reviewed research indicates that PLWD also have an increased risk of cancer-related emergency presentations, lower quality processes of cancer-related decision making, accessibility-related barriers to cancer investigations and treatment, higher experienced treatment burden and higher caregiver burden for families, and undertreated cancer-related pain. The authors propose that optimal cancer care for PLWD should focus on proactively minimizing these risk areas and thus must be highly person-centered, with holistic decision making, individualized reasonable adjustments to practice, and strong inclusion and support of family carers. Comprehensive recommendations are made for clinical practice and future research to help clinicians and providers deliver best and equitable cancer care for PLWD and their families.
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Affiliation(s)
- Laura Ashley
- School of Humanities and Social Sciences, Leeds Beckett University, Leeds, UK
| | - Claire Surr
- Centre for Dementia Research, Leeds Beckett University, Leeds, UK
| | - Rachael Kelley
- Centre for Dementia Research, Leeds Beckett University, Leeds, UK
| | - Mollie Price
- School of Humanities and Social Sciences, Leeds Beckett University, Leeds, UK
| | | | - Nicole R Fowler
- Indiana University Center for Aging Research at Regenstrief Institute, Indianapolis, Indiana, USA
| | - Dana E Giza
- Joan and Stanford Alexander Division of Geriatric and Palliative Medicine, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Richard D Neal
- Department of Health and Community Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Charlene Martin
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | | | - Anita O'Donovan
- Applied Radiation Therapy Trinity (ARTT), Discipline of Radiation Therapy, School of Medicine, Trinity St. James's Cancer Institute, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - William Dale
- Center for Cancer and Aging, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Bogda Koczwara
- Department of Medical Oncology, Flinders Medical Centre & Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| | | | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
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Schuttner L, Lee JR, Hockett Sherlock S, Ralston JD, Rosland AM, Nelson K, Simons C, Sayre GG. Primary Care Physician Perspectives on the Influence of Patient Values, Health Priorities, and Preferences on Clinical Decision-Making for Complex Patients with Multimorbidity: A Qualitative Study. Risk Manag Healthc Policy 2022; 15:2135-2146. [PMID: 36415219 PMCID: PMC9675988 DOI: 10.2147/rmhp.s380021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 10/20/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction The prevalence of patients with multimorbidity (ie, multiple chronic conditions) is increasing. Clinical decision-making guided by patients' values, health priorities and goals, and treatment preferences is particularly important in the context of interacting diseases and psychosocial needs. Physicians face challenges incorporating patient perspectives into care plans. We examined primary care physician (PCP) views on the influence of patients' values, health priorities and goals, and preferences on clinical decisions for patients with multimorbidity and increased psychosocial complexity. Methods We conducted semi-structured telephone interviews with 23 PCPs within patient-centered medical home teams in a nationally integrated health system in the United States between May and July 2020. Data were analyzed via thematic analysis with deductive and inductive coding. Results Three major themes emerged: 1. Patient personal values were rarely explicitly discussed in routine clinical encounters but informed more commonly discussed concepts of patient priorities, goals, and preferences; 2. Patient values, health priorities and goals, and preferences were sources of divergent views about care plans between healthcare teams, patients, and families; 3. Physicians used explicit strategies to communicate and negotiate about patient values, health priorities and goals, and preferences when developing care plans, including trust-building; devoting extra effort to individualizing care; connecting patient values to healthcare recommendations; deliberate elicitation and acknowledgement of patient concerns; providing "space" for patient perspectives; incorporating family into care planning; pairing physician to patient priorities; and collaborative teamwork. Conclusion Primary care physicians perceive patient values, health priorities and goals, and preferences as influential during clinical decision-making for complex patients with multimorbidity. Participants used concrete strategies to negotiate alignment of these aspects when physician-patient divergence occurred. While rarely discussed directly in clinical encounters, personal values affected patient health priorities, goals, and preferences during care planning, suggesting a clinical role for more deliberate elicitation and discussion of patient values for this population.
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Affiliation(s)
- Linnaea Schuttner
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jenney R Lee
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Stacey Hockett Sherlock
- Comprehensive Access & Delivery Research and Evaluation (CADRE) Center, VA Iowa City Health Care System, Iowa City, IA, USA
- Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - James D Ralston
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Ann-Marie Rosland
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Karin Nelson
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Carol Simons
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA
| | - George G Sayre
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
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Coates E, Wickramasekera N, Barr A, Shackley P, Lee M, Hind D, Probert C, Sebastian S, Totton N, Blackwell S, Bedford H, Dames N, Lobo A. Patient preferences and current practice for adults with steroid-resistant ulcerative colitis: POPSTER mixed-methods study. Health Technol Assess 2022; 26:1-118. [DOI: 10.3310/rhxr5192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background
Corticosteroids are a mainstay of the treatment of moderately severe relapses of ulcerative colitis, yet almost 50% of patients do not respond fully to these and risk prolonged steroid use and side effects. There is a lack of clarity about the definitions of steroid resistance, the optimum choice of treatment, and patient and health-care professional treatment preferences.
Objectives
The overall aim of this research was to understand how steroid-resistant ulcerative colitis is managed in adult secondary care and how current practice compares with patient and health-care professional preferences.
Design
A mixed-methods study, including an online survey, qualitative interviews and discrete choice experiments.
Setting
NHS inflammatory bowel disease services in the UK.
Participants
Adults with ulcerative colitis and health-care professionals treating inflammatory bowel disease.
Results
We carried out a survey of health-care professionals (n = 168), qualitative interviews with health-care professionals (n = 20) and patients (n = 33), discrete choice experiments with health-care professionals (n = 116) and patients (n = 115), and a multistakeholder workshop (n = 9). The interviews with and survey of health-care professionals showed that most health-care professionals define steroid resistance as an incomplete response to 40 mg per day of prednisolone after 2 weeks. The survey also found that anti-tumour necrosis factor drugs (particularly infliximab) are the most frequently offered drugs across most steroid-resistant (and steroid-dependent) patient scenarios, but they are less frequently offered to thiopurine-naive patients. Patient interviews identified several factors influencing their treatment choices, including effectiveness of treatment, recommendations from health-care professionals, route of administration and side effects. Over time, depending on the severity and duration of symptoms and, crucially, as medical treatment options become exhausted, patients are willing to try alternative treatments and, eventually, to undergo surgery. The discrete choice experiments found that the probability of remission and of side effects strongly influences the treatment choices of both patients and health-care professionals. Patients are less likely to choose a treatment that takes longer to improve symptoms. Health-care professionals are willing to make difficult compromises by tolerating greater safety risks in exchange for therapeutic benefits. The treatments ranked most positively by patients were infliximab and tofacitinib (each preferred by 38% of patients), and the predicted probability of uptake by health-care professionals was greatest for infliximab (62%).
Limitations
The survey and the discrete choice experiments with patients and health-care professionals are limited by their relatively small sample sizes. The qualitative studies are subject to selection bias. The timing of the different substudies, both before and during the COVID-19 pandemic, is a potential limitation.
Conclusions
We have identified factors influencing treatment decisions for steroid-resistant ulcerative colitis and the characteristics to consider when choosing treatments to evaluate in future randomised controlled trials. The findings may be used to improve discussions between patients and health-care professionals when they review treatment options for steroid-resistant ulcerative colitis.
Future work
This research highlights the need for consensus work to establish an agreed definition of steroid resistance in ulcerative colitis and a greater understanding of the optimal use of tofacitinib and surgery for this patient group. A randomised controlled trial comparing infliximab with tofacitinib is also recommended.
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 41. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Elizabeth Coates
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Amy Barr
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Phil Shackley
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Matthew Lee
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Daniel Hind
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Christopher Probert
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Shaji Sebastian
- Hull University Teaching Hospitals NHS Foundation Trust, Hull, UK
| | - Nikki Totton
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | | | | | - Alan Lobo
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Schuttner L, Hockett Sherlock S, Simons C, Ralston JD, Rosland AM, Nelson K, Lee JR, Sayre G. Factors affecting primary care physician decision-making for patients with complex multimorbidity: a qualitative interview study. BMC Prim Care 2022; 23:25. [PMID: 35123398 PMCID: PMC8817776 DOI: 10.1186/s12875-022-01633-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 01/24/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Patients with multiple chronic conditions (multimorbidity) and additional psychosocial complexity are at higher risk of adverse outcomes. Establishing treatment or care plans for these patients must account for their disease interactions, finite self-management abilities, and even conflicting treatment recommendations from clinical practice guidelines. Despite existing insight into how primary care physicians (PCPs) approach care decisions for their patients in general, less is known about how PCPs make care planning decisions for more complex populations particularly within a medical home setting. We therefore sought to describe factors affecting physician decision-making when care planning for complex patients with multimorbidity within the team-based, patient-centered medical home setting in the integrated healthcare system of the U.S. Department of Veterans Affairs, the Veterans Health Administration (VHA). METHODS This was a qualitative study involving semi-structured telephone interviews with PCPs working > 40% time in VHA clinics. Interviews were conducted from April to July, 2020. Content was analyzed with deductive and inductive thematic analysis. RESULTS 23 physicians participated in interviews; most were MDs (n = 21) and worked in hospital-affiliated clinics (n = 14) across all regions of the VHA's national clinic network. We found internal, external, and relationship-based factors, with developed subthemes describing factors affecting decision-making for complex patients with multimorbidity. Physicians described tailoring decisions to individual patients; making decisions in keeping with an underlying internal style or habit; working towards an overarching goal for care; considering impacts from patient access and resources on care plans; deciding within boundaries provided by organizational structures; collaborating on care plans with their care team; and impacts on decisions from their own emotions and relationship with patient. CONCLUSIONS PCPs described internal, external, and relationship-based factors that affected their care planning for high-risk and complex patients with multimorbidity in the VHA. Findings offer useful strategies employed by physicians to effectively conduct care planning for complex patients in a medical home setting, such as delegation of follow-up within multidisciplinary care teams, optimizing visit time vs frequency, and deliberate investment in patient-centered relationship building to gain buy-in to care plans.
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Affiliation(s)
- Linnaea Schuttner
- Health Services Research & Development, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, Washington, 98108, USA. .,Department of Medicine, University of Washington, Seattle, WA, USA.
| | - Stacey Hockett Sherlock
- Comprehensive Access & Delivery Research and Evaluation (CADRE) Center, VA Iowa City Health Care System, Iowa City, IA, USA.,Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Carol Simons
- Health Services Research & Development, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, Washington, 98108, USA
| | - James D Ralston
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.,Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Ann-Marie Rosland
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Karin Nelson
- Health Services Research & Development, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, Washington, 98108, USA.,Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Jennifer R Lee
- Health Services Research & Development, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, Washington, 98108, USA.,Department of Urology, University of Washington, Seattle, WA, USA
| | - George Sayre
- Health Services Research & Development, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, Washington, 98108, USA.,Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
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Cohen-Stavi CJ, Giveon S, Key C, Molcho T, Balicer R, Shadmi E. Guideline deviation and its association with specific chronic diseases among patients with multimorbidity: a cross-sectional cohort study in a care management setting. BMJ Open 2021; 11:e040961. [PMID: 33431488 PMCID: PMC7802706 DOI: 10.1136/bmjopen-2020-040961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To assess whether the extent of deviation from chronic disease guideline recommendations is more prominent for specific diseases compared with combined-care across multiple conditions among multimorbid patients, and to examine reasons for this deviation. DESIGN A cross-sectional cohort. SETTING Multimorbidity care management programme across 11 primary care clinics. PATIENTS Patients aged 45-95 years with at least two common chronic conditions, sampled according to being new (≤6 months) or veteran (≥1 year) to the programme. MAIN OUTCOME MEASURES Deviation from guideline-recommended care was measured for each patient's relevant conditions, aggregated and stratified across disease groups, calculated as measures of 'disease-specific' guideline deviation and 'combined-care' (all conditions) guideline deviation for: atrial fibrillation, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disorder, depression, diabetes, dyslipidaemia, hypertension and ischaemic heart disease. Combined-care deviation was evaluated for its association with specific diseases. Frequencies of previously derived reason types for deviation (biomedical, patient personal and contextual) were reported by nurse care managers, assessed across diseases and evaluated for their association with specific diseases. RESULTS Among 204 patients, disease-specific deviation varied more (from 14.7% to 48.2%) across diseases than combined-care deviation (from 14.7% to 25.6%). Depression and diabetes were significantly associated with more deviation (mean: 6% (95% CI: 2% to 10%) and 5% (95% CI: 2% to 9%), respectively). For some conditions, assessments were among small patient samples. Guideline deviation was often attributed to non-disease-specific reasons, such as physical limitations or care burden, as much as disease-specific reasons, which was reflected in the likelihood for guideline deviation to be due to different types of reasons for some diseases. CONCLUSIONS When multimorbid patients are considered in disease groups rather than as 'whole persons', as in many quality of care studies, the cross-cutting factors in their care delivery can be missed. The types of reasons more likely to occur for specific diseases may inform improvement strategies. TRIAL REGISTRATION NUMBER NCT01811173; Pre-results.
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Affiliation(s)
- Chandra J Cohen-Stavi
- Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel
- The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Shmuel Giveon
- Community Medical Division, Clalit Health Services, Tel Aviv, Israel
| | - Calanit Key
- Community Nursing Division, Clalit Health Services, Tel Aviv, Israel
| | - Tchiya Molcho
- Community Nursing Division, Clalit Health Services, Tel Aviv, Israel
| | - Ran Balicer
- Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel
- Public Health Department, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Efrat Shadmi
- Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel
- The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
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