Proceedings From a National Heart, Lung, and Blood Institute and the Centers for Disease Control and Prevention Workshop to Control Hypertension

Hypertension treatment and control prevent more cardiovascular events than management of other modifiable risk factors. Although the age-adjusted proportion of US adults with controlled blood pressure (BP) defined as <140/90 mm Hg, improved from 31.8% in 1999-2000 to 48.5% in 2007-2008, it remained stable through 2013-2014 and declined to 43.7% in 2017-2018. To address the rapid decline in hypertension control, the National Heart, Lung, and Blood Institute and the Division for Heart Disease and Stroke Prevention of the Centers for Disease Control and Prevention convened a virtual workshop with multidisciplinary national experts. Also, the group sought to identify opportunities to reverse the adverse trend and further improve hypertension control. The workshop immediately preceded the Surgeon General's Call to Action to Control Hypertension, which recognized a stagnation in progress with hypertension control. The presentations and discussions included potential reasons for the decline and challenges in hypertension control, possible "big ideas," and multisector approaches that could reverse the current trend while addressing knowledge gaps and research priorities. The broad set of "big ideas" was comprised of various activities that may improve hypertension control, including: interventions to engage patients, promotion of self-measured BP monitoring with clinical support, supporting team-based care, implementing telehealth, enhancing community-clinical linkages, advancing precision population health, developing tailored public health messaging, simplifying hypertension treatment, using process and outcomes quality metrics to foster accountability and efficiency, improving access to high-quality health care, addressing social determinants of health, supporting cardiovascular public health and research, and lowering financial barriers to hypertension control.

Patient-Centered Approaches to Transitional Care Research and Implementation: Overview and Insights From Patient-Centered Outcomes Research Institute's Transitional Care Portfolio

BACKGROUND

This Special Issue, Future Directions in Transitional Care Research, focuses on the approaches used and lessons learned by researchers conducting care transitions studies funded by the Patient-Centered Outcomes Research Institute (PCORI). PCORI's approach to transitional care research augments prior research by encouraging researchers to focus on head-to-head comparisons of interventions, the use of patient-centered outcomes, and the engagement of stakeholders throughout the research process.

OBJECTIVES

This paper introduces the themes and topics addressed by the articles that follow, which are focused on opportunities and challenges involved in conducting patient-centered clinical comparative effectiveness research in transitional care. It provides an overview of the state of the care transitions field, a description of PCORI's programmatic objectives, highlights of the patient and stakeholder engagement activities that have taken place during the course of these studies, and a brief overview of PCORI's Transitional Care Evidence to Action Network, a learning community designed to foster collaboration between investigators and their research teams and enhance the collective impact of this body of work.

CONCLUSIONS

The papers in this Special Issue articulate challenges, lessons learned, and new directions for measurement, stakeholder engagement, implementation, and methodological and design approaches that reflect the complexity of transitional care comparative effectiveness research and seek to move the field toward a more holistic understanding of transitional care that integrates social needs and lifespan development into our approaches to improving care transitions.

Comparative Clinical Effectiveness Research Focused on Community-Based Delivery of Palliative Care: Overview of the Patient-Centered Outcomes Research Institute's Funding Initiative

Palliative care is a growing specialty that addresses the needs of individuals diagnosed with advanced illness and their caregivers. Although palliative care has been shown to improve a variety of patient- and caregiver-centered outcomes, access to comprehensive palliative care services for patients is often limited. There is a need to identify the most effective approaches to delivering palliative care to patients in community settings. In fiscal year 2017, based on extensive input from a diverse set of stakeholders, the Patient-Centered Outcomes Research Institute (PCORI) funded nine multisite comparative clinical effectiveness research (CER) trials focused on community-based delivery of palliative care for a total investment of $80 million. These studies, focusing on advance care planning and models of palliative care delivery, represent some of the largest most complex palliative care trials funded to date. Each study evaluates both patient and caregiver outcomes, and together, these trials include a broad range of health conditions, interventions, and settings of care. PCORI has also fostered a learning network of the funded awardees to facilitate the successful conduct of these CER studies and to support awardee efforts to develop collaborative products relevant to advancing the field of palliative care research and practice. The protocols of each of the nine trials, detailed in this issue, demonstrate the expansive reach of the investment PCORI has made in an effort to further the research agenda and provide substantive research evidence in stakeholder-identified areas of need in the field of palliative care.

ASSESSMENT OF COMPARATIVE EFFECTIVENESS RESEARCH GAPS TO PROMOTE AGING IN PLACE: A STAKEHOLDER-DRIVEN APPROACH

A priority for many older adults is to remain in their homes and communities. This paper describes the Patient-Centered Outcomes Research Institute’s (PCORI) review of our investment in comparative effectiveness research (CER) that will advance the field of “aging in place.” To inform our systematic evaluation, we first engaged our multi-stakeholder advisory panel of patients/caregivers, clinicians, health systems leaders, and payers to develop and refine a conceptual framework for research focused on aging in place among older adults. Key themes from stakeholders were: aging in place interventions should be patient-centered and align with the patients’ needs and goals, studies should include individuals 55+ years who may be at risk for institutionalization, relevant interventions go beyond environmental modifications and include social support, healthcare (inclusive of palliative care), and personal care services. In addition, aging in place services should focus more on informal caregiver interventions and outcomes since informal caregivers play a major role in enabling older adults to age in place. We identified 14 PCORI-funded CER projects that will provide evidence on the most effective interventions to promote aging in place among older adults; the total investment is $113.4 million dollars. The portfolio is addressing decisional dilemmas faced by multiple stakeholders on a variety of topics including falls prevention, home-based palliative care, and community-based care models; however, several critical CER evidence gaps remain that need to be addressed in future funding investments and will be discussed during the presentation.

CAREGIVERS OF OLDER ADULTS: AN ANALYSIS OF THE PCORI FUNDED RESEARCH PORTFOLIO

A family-centered approach to care is vital, and caregivers play an important role in patient-centered care for older adults. This analysis of the Patient-Centered Outcomes Research Institute’s (PCORI) portfolio of clinical comparative effectiveness research (CER) trials explores the extent to which caregiving for older adults is a focus within our funded studies and examines how these studies incorporate interventions and outcomes related to caregivers. Of 116 studies in the portfolio with a caregiving component, only 35 studies focus on caregivers of older adults. Approximately half of these studies (16) were not focused on a specific disease, but rather included older adults with a variety of diseases. Caregivers were the target of a delivered intervention in 18 studies. Among these studies, all but one included caregivers as part of a multicomponent intervention. The most common intervention components were caregiver training (14 studies) and inclusion of caregivers in the delivery of health services, notably coordination of care (17), home visits (9), integrated care (9), multidisciplinary care teams (9), and clinical decision tools (8). Caregiver-focused outcomes were assessed in 26 studies. The most frequently assessed domains include measures of health and well-being (most commonly psychosocial status; n=20), evaluation of care (most commonly satisfaction; n=8), and health behavior (most commonly attitudes; n=6). In general, given stakeholder interest in family-centered research on older adults, future CER research should include caregivers and/or compare interventions focused solely on the unique needs of caregivers of older adults. Inclusion of caregiver-related outcomes should also be promoted.

Perceptions of Patients With Breast and Colon Cancer of the Management of Cancer-Related Pain, Fatigue, and Emotional Distress in Community Oncology

PURPOSE

Pain, fatigue, and distress are common among patients with cancer but are often underassessed and undertreated. We examine the prevalence of pain, fatigue, and emotional distress among patients with cancer, as well as patient perceptions of the symptom care they received.

PATIENTS AND METHODS

Seventeen Commission on Cancer-accredited cancer centers across the United States sampled patients with local/regional breast (82%) or colon (18%) cancer. We received 2,487 completed surveys (61% response rate).

RESULTS

Of patients, 76%, 78%, and 59% reported talking to a clinician about pain, fatigue, and distress, respectively, and 70%, 61%, and 54% reported receiving advice. Sixty-one percent of patients experienced pain, 74% fatigue, and 46% distress. Among those patients experiencing each symptom, 58% reported getting the help they wanted for pain, 40% for fatigue, and 45% for distress. Multilevel logistic regression models revealed that patients experiencing symptoms were significantly more likely to have talked about and received advice on coping with these symptoms. In addition, patients who were receiving or recently completed curative treatment reported more symptoms and better symptom care than did those who were further in time from curative treatment.

CONCLUSION

In our sample, 30% to 50% of patients with cancer in community cancer centers did not report discussing, getting advice, or receiving desired help for pain, fatigue, or emotional distress. This finding suggests that there is room for improvement in the management of these three common cancer-related symptoms. Higher proportions of talk and advice among those experiencing symptoms imply that many discussions may be patient initiated. Lower rates of talk and advice among those who are further in time from treatment suggest the need for more assessment among longer-term survivors, many of whom continue to experience these symptoms. These findings seem to be especially important given the high prevalence of these symptoms in our sample.

Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE): A Cluster-Randomized Pragmatic Trial of a Multifactorial Fall Injury Prevention Strategy: Design and Methods

Background

Fall injuries are a major cause of morbidity and mortality among older adults. We describe the design of a pragmatic trial to compare the effectiveness of an evidence-based, patient-centered multifactorial fall injury prevention strategy to an enhanced usual care.

Methods

Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) is a 40-month cluster-randomized, parallel-group, superiority, pragmatic trial being conducted at 86 primary care practices in 10 health care systems across United States. The 86 practices were randomized to intervention or control group using covariate-based constrained randomization, stratified by health care system. Participants are community-living persons, ≥70 years, at increased risk for serious fall injuries. The intervention is a comanagement model in which a nurse Falls Care Manager performs multifactorial risk assessments, develops individualized care plans, which include surveillance, follow-up evaluation, and intervention strategies. Control group receives enhanced usual care, with clinicians and patients receiving evidence-based information on falls prevention. Primary outcome is serious fall injuries, operationalized as those leading to medical attention (nonvertebral fractures, joint dislocation, head injury, lacerations, and other major sequelae). Secondary outcomes include all fall injuries, all falls, and well-being (concern for falling; anxiety and depressive symptoms; physical function and disability). Target sample size was 5,322 participants to provide 90% power to detect 20% reduction in primary outcome rate relative to control.

Results

Trial enrolled 5,451 subjects in 20 months. Intervention and follow-up are ongoing.

Conclusions

The findings of the STRIDE study will have important clinical and policy implications for the prevention of fall injuries in older adults.

The National Cancer Institute Community Cancer Centers Program (NCCCP): Sustaining Quality and Reducing Disparities in Guideline-Concordant Breast and Colon Cancer Care

This study builds on analyses performed as part of an original comprehensive National Cancer Institute Community Cancer Centers Program evaluation and examines improvements in quality of care. The following research questions are addressed: (a) have improvements in concordance rates with the five quality of care measures been sustained since 2010 and (b) how does the change in concordance for minority/underserved patients compare to the change for nonminority/nonunderserved patients through 2013?

Background.

The National Cancer Institute Community Cancer Centers Program (NCCCP) pilot was designed to improve quality of cancer care and reduce disparities at community hospitals. The NCCCP's primary intervention was the implementation of the Commission on Cancer Rapid Quality Reporting System (RQRS). The RQRS is a hospital‐based data collection and evaluation system allowing near real‐time assessment of selected breast and colon cancer quality of care measures. Building on previous NCCCP analyses, this study examined whether improvements in quality cancer care within NCCCP hospitals early in the program were sustained and whether improvements were notable for minority or underserved populations.

Methods.

We compared changes in concordance with three breast and two colon cancer quality measures approved by the National Quality Forum for patients diagnosed at NCCCP hospitals from 2006 to 2007 (pre‐RQRS), 2008 to 2010 (early‐RQRS), and 2011 to 2013 (later‐RQRS). Data were obtained from NCCCP sites participating in the Commission on Cancer Rapid Quality Reporting System. Logistic regression analyses were performed to identify predictors of concordance with breast and colon cancer quality measures.

Results.

The sample included 13,893 breast and 5,546 colon cancer patients. After RQRS initiation, all five quality measures improved significantly and improvements were sustained through 2013. Quality of care measures showed sustained improvements for both breast and colon cancer patients and for vulnerable patient subgroups including black, uninsured, and Medicaid‐covered patients.

Conclusions.

Quality improvements in NCCCP hospitals were sustained throughout the duration of the program, both overall and among minority and underserved patients. Because many individuals receive cancer treatment at community hospitals, facilitating high‐quality care in these environments must be a priority.

Implications for Practice.

Quality improvement programs often improve practice, but the methods are not maintained over time. The implementation of a real‐time quality reporting system and a network focused on improving quality of care sustained quality improvement at select community cancer centers. The NCCCP pilot increased numbers of patients receiving guideline‐concordant care for breast and colon cancer in community settings, and initial improvements noted in earlier years of RQRS were sustained into later years, both overall and among minority and underserved patients. National initiatives that improve care for diverse patient groups are important for reducing and eliminating barriers to care.

Walking in the shoes of patients, not just in their genes: a patient-centered approach to genomic medicine

Genomic technologies are increasing the precision with which clinicians can assess an individual patient's risk for developing diseases and identify which patients are likely to benefit from specific treatments. Also advocating for a shift away from a one-size-fits-all approach is the growing emphasis on "patient-centered" care. Using examples from breast cancer, we make a case for why, in order to optimize patient health outcomes, genomic medicine will need to be practiced within a patient-centered framework. We present a six-function conceptual framework for patient-centered care and discuss findings from a national survey evaluating the patient-centeredness of care delivered in the USA.

Validity and Reliability of the US National Cancer Institute's Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE)

IMPORTANCE

To integrate the patient perspective into adverse event reporting, the National Cancer Institute developed a patient-reported outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE).

OBJECTIVE

To assess the construct validity, test-retest reliability, and responsiveness of PRO-CTCAE items.

DESIGN, SETTING, AND PARTICIPANTS

A total of 975 adults with cancer undergoing outpatient chemotherapy and/or radiation therapy enrolled in this questionnaire-based study between January 2011 and February 2012. Eligible participants could read English and had no clinically significant cognitive impairment. They completed PRO-CTCAE items on tablet computers in clinic waiting rooms at 9 US cancer centers and community oncology practices at 2 visits 1 to 6 weeks apart. A subset completed PRO-CTCAE items during an additional visit 1 business day after the first visit.

MAIN OUTCOMES AND MEASURES

Primary comparators were clinician-reported Eastern Cooperative Oncology Group Performance Status (ECOG PS) and the European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire (QLQ-C30).

RESULTS

A total of 940 of 975 (96.4%) and 852 of 940 (90.6%) participants completed PRO-CTCAE items at visits 1 and 2, respectively. At least 1 symptom was reported by 938 of 940 (99.8%) participants. Participants' median age was 59 years; 57.3% were female, 32.4% had a high school education or less, and 17.1% had an ECOG PS of 2 to 4. All PRO-CTCAE items had at least 1 correlation in the expected direction with a QLQ-C30 scale (111 of 124, P<.05 for all). Stronger correlations were seen between PRO-CTCAE items and conceptually related QLQ-C30 domains. Scores for 94 of 124 PRO-CTCAE items were higher in the ECOG PS 2 to 4 vs 0 to 1 group (58 of 124, P<.05 for all). Overall, 119 of 124 items met at least 1 construct validity criterion. Test-retest reliability was 0.7 or greater for 36 of 49 prespecified items (median [range] intraclass correlation coefficient, 0.76 [0.53-.96]). Correlations between PRO-CTCAE item changes and corresponding QLQ-C30 scale changes were statistically significant for 27 prespecified items (median [range] r=0.43 [0.10-.56]; all P≤.006).

CONCLUSIONS AND RELEVANCE

Evidence demonstrates favorable validity, reliability, and responsiveness of PRO-CTCAE in a large, heterogeneous US sample of patients undergoing cancer treatment. Studies evaluating other measurement properties of PRO-CTCAE are under way to inform further development of PRO-CTCAE and its inclusion in cancer trials.

Cancer Care Delivery Research: Building the Evidence Base to Support Practice Change in Community Oncology

Understanding how health care system structures, processes, and available resources facilitate and/or hinder the delivery of quality cancer care is imperative, especially given the rapidly changing health care landscape. The emerging field of cancer care delivery research (CCDR) focuses on how organizational structures and processes, care delivery models, financing and reimbursement, health technologies, and health care provider and patient knowledge, attitudes, and behaviors influence cancer care quality, cost, and access and ultimately the health outcomes and well-being of patients and survivors. In this article, we describe attributes of CCDR, present examples of studies that illustrate those attributes, and discuss the potential impact of CCDR in addressing disparities in care. We conclude by emphasizing the need for collaborative research that links academic and community-based settings and serves simultaneously to accelerate the translation of CCDR results into practice. The National Cancer Institute recently launched its Community Oncology Research Program, which includes a focus on this area of research.

Unveiling SEER-CAHPS®: a new data resource for quality of care research

BACKGROUND

Since 1990, the National Cancer Institute (NCI) and Centers for Medicare and Medicaid Services (CMS) have collaborated to create linked data resources to improve our understanding of patterns of care, health care costs, and trends in utilization. However, existing data linkages have not included measures of patient experiences with care.

OBJECTIVE

To describe a new resource for quality of care research based on a linkage between the Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS®) patient surveys and the NCI's Surveillance, Epidemiology and End Results (SEER) data.

DESIGN

This is an observational study of CAHPS respondents and includes both fee-for-service and Medicare Advantage beneficiaries with and without cancer. The data linkage includes: CAHPS survey data collected between 1998 and 2010 to assess patient reports on multiple aspects of their care, such as access to needed and timely care, doctor communication, as well as patients' global ratings of their personal doctor, specialists, overall health care, and their health plan; SEER registry data (1973-2007) on cancer site, stage, treatment, death information, and patient demographics; and longitudinal Medicare claims data (2002-2011) for fee-for-service beneficiaries on utilization and costs of care.

PARTICIPANTS

In total, 150,750 respondents were in the cancer cohort and 571,318 were in the non-cancer cohort.

MAIN MEASURES

The data linkage includes SEER data on cancer site, stage, treatment, death information, and patient demographics, in addition to longitudinal data from Medicare claims and information on patient experiences from CAHPS surveys.

KEY RESULTS

Sizable proportions of cases from common cancers (e.g., breast, colorectal, prostate) and short-term survival cancers (e.g., pancreas) by time since diagnosis enable comparisons across the cancer care trajectory by MA vs. FFS coverage.

CONCLUSIONS

SEER-CAHPS is a valuable resource for information about Medicare beneficiaries' experiences of care across different diagnoses and treatment modalities, and enables comparisons by type of insurance.

Patient Centeredness and Engagement in Quality-of-Care Oncology Research

More than a decade after the Institute of Medicine (IOM) first studied the quality of cancer care, obstacles to achieving high-quality care remain, and studies suggest that cancer care is often not as patient centered, accessible, coordinated, or evidence based as it could be. Patients, their families, and clinicians face a wide range of complex and often confusing choices regarding their health and health care concerns and require trustworthy information to decide which options are best for them. The Patient-Centered Outcomes Research Institute (PCORI) strives to fund clinical comparative effectiveness research, guided by patients, caregivers, and the broader health care community, that will provide high-integrity, evidence-based information to help people make informed health care decisions. This mission is well aligned with the IOM's recent conceptual framework and corresponding recommendations that recognize that addressing the needs of patients with cancer and their families is the most important component of a high-quality cancer care delivery system. PCORI seeks the opportunity to partner with diverse interdisciplinary research teams who demonstrate a strong commitment to the inclusion and engagement of patients and stakeholders as they work to develop high-quality cancer care delivery systems. We see rich opportunities for such partnership in the cancer care community, given the wealth of well-established patient advocacy groups and organizations and cutting-edge research institutions, all of which are working toward the common goal of improving the quality of cancer care for patients and their families. This article and the project it describes provide an example of an avenue for advancing this goal.

Patient characteristics associated with the level of patient-reported care coordination among male patients with colorectal cancer in the Veterans Affairs health care system

BACKGROUND

The current study was performed to determine whether patient characteristics, including race/ethnicity, were associated with patient-reported care coordination for patients with colorectal cancer (CRC) who were treated in the Veterans Affairs (VA) health care system, with the goal of better understanding potential goals of quality improvement efforts aimed at improving coordination.

METHODS

The nationwide Cancer Care Assessment and Responsive Evaluation Studies survey involved VA patients with CRC who were diagnosed in 2008 (response rate, 67%). The survey included a 4-item scale of patient-reported frequency ("never," "sometimes," "usually," and "always") of care coordination activities (scale score range, 1-4). Among 913 patients with CRC who provided information regarding care coordination, demographics, and symptoms, multivariable logistic regression was used to examine odds of patients reporting optimal care coordination.

RESULTS

VA patients with CRC were found to report high levels of care coordination (mean scale score, 3.50 [standard deviation, 0.61]). Approximately 85% of patients reported a high level of coordination, including the 43% reporting optimal/highest-level coordination. There was no difference observed in the odds of reporting optimal coordination by race/ethnicity. Patients with early-stage disease (odds ratio [OR], 0.60; 95% confidence interval [95% CI], 0.45-0.81), greater pain (OR, 0.97 for a 1-point increase in pain scale; 95% CI, 0.96-0.99), and greater levels of depression (OR, 0.97 for a 1-point increase in depression scale; 95% CI, 0.96-0.99) were less likely to report optimal coordination.

CONCLUSIONS

Patients with CRC in the VA reported high levels of care coordination. Unlike what has been reported in settings outside the VA, there appears to be no racial/ethnic disparity in reported coordination. However, challenges remain in ensuring coordination of care for patients with less advanced disease and a high symptom burden. Cancer 2015;121:2207-2213. © 2015 American Cancer Society.

Quality improvement in the national cancer institute community cancer centers program: the quality oncology practice initiative experience

PURPOSE

The National Cancer Institute (NCI) Community Cancer Centers Program (NCCCP) began in 2007; it is a network of community-based hospitals funded by the NCI. Quality of care is an NCCCP priority, with participation in the American Society of Clinical Oncology Quality Oncology Practice Initiative (QOPI) playing a fundamental role in quality assessment and quality improvement (QI) projects. Using QOPI methodology, performance on quality measures was analyzed two times per year over a 3-year period to enhance our implementation of quality standards at NCCCP hospitals.

METHODS

A data-sharing agreement allowed individual-practice QOPI data to be electronically sent to the NCI. Aggregated data with the other NCCCP QOPI participants were presented to the network via Webinars. The NCCCP Quality of Care Subcommittee selected areas in which to focus subsequent QI efforts, and high-performing practices shared voluntarily their QI best practices with the network.

RESULTS

QOPI results were compiled semiannually between fall 2010 and fall 2013. The network concentrated on measures with a quality score of ≤ 0.75 and planned voluntary group-wide QI interventions. We identified 13 measures in which the NCCCP fell at or below the designated quality score in fall 2010. After implementing a variety of QI initiatives, the network registered improvements in all parameters except one (use of treatment summaries).

CONCLUSION

Using the NCCCP as a paradigm, QOPI metrics provide a useful platform for group-wide measurement of quality performance. In addition, these measurements can be used to assess the effectiveness of QI initiatives.

Health-related quality of life in older adult survivors of selected cancers: data from the SEER-MHOS linkage

BACKGROUND

Research on health-related quality of life (HRQOL) among older adult cancer survivors is mostly confined to breast cancer, prostate cancer, colorectal cancer, and lung cancer, which account for 63% of all prevalent cancers. Much less is known about HRQOL in the context of less common cancer sites.

METHODS

HRQOL was examined with the 36-Item Short Form Health Survey, version 1, and the Veterans RAND 12-Item Health Survey in patients with selected cancers (kidney cancer, bladder cancer, pancreatic cancer, upper gastrointestinal cancer, cancer of the oral cavity and pharynx, uterine cancer, cervical cancer, thyroid cancer, melanoma, chronic leukemia, non-Hodgkin lymphoma, and multiple myeloma) and in individuals without cancer on the basis of data linked from the Surveillance, Epidemiology, and End Results cancer registry system and the Medicare Health Outcomes Survey. Scale scores, Physical Component Summary (PCS) and Mental Component Summary (MCS) scores, and a utility metric (Short Form 6D/Veterans RAND 6D), adjusted for sociodemographic characteristics and other chronic conditions, were calculated. A 3-point difference in the scale scores and a 2-point difference in the PCS and MCS scores were considered to be minimally important differences.

RESULTS

Data from 16,095 cancer survivors and 1,224,549 individuals without a history of cancer were included. The results indicated noteworthy deficits in physical health status. Mental health was comparable, although scores for the Role-Emotional and Social Functioning scales were worse for patients with most types of cancer versus those without cancer. Survivors of multiple myeloma and pancreatic malignancies reported the lowest scores, with their PCS/MCS scores less than those of individuals without cancer by 3 or more points.

CONCLUSIONS

HRQOL surveillance efforts revealed poor health outcomes among many older adults and specifically among survivors of multiple myeloma and pancreatic cancer.

Assessing the Development of Multidisciplinary Care: Experience of the National Cancer Institute Community Cancer Centers Program

PURPOSE

The National Cancer Institute Community Cancer Centers Program (NCCCP) began in 2007 with a goal of expanding cancer research and delivering quality care in communities. The NCCCP Quality of Care (QoC) Subcommittee was charged with developing and improving the quality of multidisciplinary care. An assessment tool with nine key elements relevant to MDC structure and operations was developed.

METHODS

Fourteen NCCCP sites reported multidisciplinary care assessments for lung, breast, and colorectal cancer in June 2010, June 2011, and June 2012 using an online reporting tool. Each site evaluated their level of maturity (level 1 = no multidisciplinary care, level 5 = highly integrated multidisciplinary care) in nine elements integral to multidisciplinary care. Thematic analysis of open-ended qualitative responses was also conducted.

RESULTS

The proportion of sites that reported level 3 or greater on the assessment tool was tabulated at each time point. For all tumor types, sites that reached this level increased in six elements: case planning, clinical trials, integration of care coordination, physician engagement, quality improvement, and treatment team integration. Factors that enabled improvement included increasing organizational support, ensuring appropriate physician participation, increasing patient navigation, increasing participation in national quality initiatives, targeting genetics referrals, engaging primary care providers, and integrating clinical trial staff.

CONCLUSIONS

Maturation of multidisciplinary care reflected focused work of the NCCCP QoC Subcommittee. Working group efforts in patient navigation, genetics, and physician conditions of participation were evident in improved multidisciplinary care performance for three common malignancies. This work provides a blueprint for health systems that wish to incorporate prospective multidisciplinary care into their cancer programs.

Discussions about clinical trials among patients with newly diagnosed lung and colorectal cancer

BACKGROUND

Clinical trials are essential to establish the effectiveness of new cancer therapies, but less than 5% of adults with cancer enroll in trials. In addition to ineligibility or lack of available trials, barriers to enrollment may include limited patient awareness about the option of participation.

METHODS

We surveyed a multiregional cohort of patients with lung or colorectal cancer (or their surrogates) three to six months after diagnosis. We assessed whether respondents reported learning that clinical trial participation might be an option, and, if so, with whom they discussed trials. We used logistic regression to assess the association of patient characteristics with discussing trial participation and enrolling in trials. All statistical tests were two-sided.

RESULTS

Of 7887 respondents, 1114 (14.1%) reported discussing the possibility of clinical trial participation; most learned about trials from their physicians, and 287 patients (3.6% of all patients, 25.8% of trial discussants) enrolled. Among 2173 patients who received chemotherapy for advanced (stage III/IV lung or stage IV colorectal) cancer, 25.7% discussed trials, and 7.6% (29.5% of trial discussants) enrolled. Discussions were less frequent among older patients, African American or Asian vs white patients, and those with lower incomes and more comorbidity. Enrollment was higher among patients reporting shared vs physician-driven decisions (all P < .05).

CONCLUSIONS

In this population-based cohort, only 14% of patients discussed participation in clinical trials. Discussions were more frequent among advanced cancer patients but were still reported by a minority of patients. Strategies to expand access to trials and facilitate patient-provider communication about participation may accelerate development of better cancer therapeutics.

Development of the National Cancer Institute's patient-reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE)

The standard approach for documenting symptomatic adverse events (AEs) in cancer clinical trials involves investigator reporting using the National Cancer Institute's (NCI's) Common Terminology Criteria for Adverse Events (CTCAE). Because this approach underdetects symptomatic AEs, the NCI issued two contracts to create a patient-reported outcome (PRO) measurement system as a companion to the CTCAE, called the PRO-CTCAE. This Commentary describes development of the PRO-CTCAE by a group of multidisciplinary investigators and patient representatives and provides an overview of qualitative and quantitative studies of its measurement properties. A systematic evaluation of all 790 AEs listed in the CTCAE identified 78 appropriate for patient self-reporting. For each of these, a PRO-CTCAE plain language term in English and one to three items characterizing the frequency, severity, and/or activity interference of the AE were created, rendering a library of 124 PRO-CTCAE items. These items were refined in a cognitive interviewing study among patients on active cancer treatment with diverse educational, racial, and geographic backgrounds. Favorable measurement properties of the items, including construct validity, reliability, responsiveness, and between-mode equivalence, were determined prospectively in a demographically diverse population of patients receiving treatments for many different tumor types. A software platform was built to administer PRO-CTCAE items to clinical trial participants via the internet or telephone interactive voice response and was refined through usability testing. Work is ongoing to translate the PRO-CTCAE into multiple languages and to determine the optimal approach for integrating the PRO-CTCAE into clinical trial workflow and AE analyses. It is envisioned that the PRO-CTCAE will enhance the precision and patient-centeredness of adverse event reporting in cancer clinical research.

Patient-reported quality of supportive care among patients with colorectal cancer in the Veterans Affairs Health Care System

PURPOSE

High-quality supportive care is an essential component of comprehensive cancer care. We implemented a patient-centered quality of cancer care survey to examine and identify predictors of quality of supportive care for bowel problems, pain, fatigue, depression, and other symptoms among 1,109 patients with colorectal cancer.

PATIENTS AND METHODS

Patients with new diagnosis of colorectal cancer at any Veterans Health Administration medical center nationwide in 2008 were ascertained through the Veterans Affairs Central Cancer Registry and sent questionnaires assessing a variety of aspects of patient-centered cancer care. We received questionnaires from 63% of eligible patients (N = 1,109). Descriptive analyses characterizing patient experiences with supportive care and binary logistic regression models were used to examine predictors of receipt of help wanted for each of the five symptom categories.

RESULTS

There were significant gaps in patient-centered quality of supportive care, beginning with symptom assessment. In multivariable modeling, the impact of clinical factors and patient race on odds of receiving wanted help varied by symptom. Coordination of care quality predicted receipt of wanted help for all symptoms, independent of patient demographic or clinical characteristics.

CONCLUSION

This study revealed substantial gaps in patient-centered quality of care, difficult to characterize through quality measurement relying on medical record review alone. It established the feasibility of collecting patient-reported quality measures. Improving quality measurement of supportive care and implementing patient-reported outcomes in quality-measurement systems are high priorities for improving the processes and outcomes of care for patients with cancer.

Cognitive interviewing of the US National Cancer Institute's Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE)

PURPOSE

The National Cancer Institute's Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) is a library of question items that enables patient reporting of adverse events (AEs) in clinical trials. This study contributes content validity evidence of the PRO-CTCAE by incorporating cancer patient input of the relevance and comprehensiveness of the item library.

METHODS

Cognitive interviews were conducted among patients undergoing chemotherapy or radiation therapy at multiple sites to evaluate comprehension, memory retrieval, judgment, and response mapping related to AE terms (e.g., nausea), attribute terms (regarding frequency, severity, or interference), response options, and recall period. Three interview rounds were conducted with ≥20 patients completing each item per round. Items were modified and retested if ≥3 patients exhibited cognitive difficulties or if experienced by ≤25% patients.

RESULTS

One hundred and twenty-seven patients participated (35% ≤high school, 28% non-white, and 59% female). Most AE terms (63/80) generated no cognitive difficulties. The remaining 17 were modified without further difficulties by Round 3. Terms were comprehended regardless of education level. Attribute terms and response options required no modifications. Patient adherence to recall period (7 days) was improved when the reference period was incorporated.

CONCLUSIONS

This study provides evidence confirming comprehension of the US English language versions of items in the PRO-CTCAE library for measuring symptomatic AEs from the patient perspective within the context of cancer treatment. Several minor changes were made to the items to improve item clarity, comprehension, and ease of response judgment. This study helps to establish the content validity of PRO-CTCAE items for patient reporting of AEs during cancer treatment.

Organization of Primary Care Practice for Providing Energy Balance Care

Purpose.

Primary care physicians (PCPs) may not adequately counsel or monitor patients regarding diet, physical activity, and weight control (i.e., provide energy balance care). We assessed the organization of PCPs' practices for providing this care.

Design.

The study design was a nationally representative survey conducted in 2008.

Setting.

The study setting was U.S. primary care practices.

Subjects.

A total of 1740 PCPs completed two sequential questionnaires (response rate, 55.5%).

Measures.

The study measured PCPs' reports of practice resources, and the frequency of body mass index assessment, counseling, referral for further evaluation/management, and monitoring of patients for energy balance care.

Analysis.

Descriptive statistics and logistic regression modeling were used.

Results.

More than 80% of PCPs reported having information resources on diet, physical activity, or weight control available in waiting/exam rooms, but fewer billed (45%), used reminder systems (< 30%), or received incentive payments (3%) for energy balance care. A total of 26% reported regularly assessing body mass index and always/often providing counseling as well as tracking patients for progress related to energy balance. In multivariate analyses, PCPs in practices with full electronic health records or those that bill for energy balance care provided this care more often and more comprehensively. There were strong specialty differences, with pediatricians more likely (odds ratio, 1.78; 95% confidence interval, 1.26–2.51) and obstetrician/gynecologists less likely (odds ratio, 0.28; 95% confidence interval, 0.17–0.44) than others to provide energy balance care.

Conclusion.

PCPs' practices are not well organized for providing energy balance care. Further research is needed to understand PCP care-related specialty differences.

Stakeholder perspectives on implementing the National Cancer Institute's patient-reported outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE)

The National Cancer Institute (NCI) is developing a patient-reported version of its Common Terminology Criteria for Adverse Events, called the "PRO-CTCAE." The PRO-CTCAE consists of a library of patient-reported items which can be administered in clinical trials to directly capture the patient experience of adverse events during cancer treatment, as well as a software platform for administering these items via computer or telephone. In order to better understand the impressions of stakeholders involved in cancer clinical research about the potential value of the PRO-CTCAE approach to capturing adverse event information in clinical research, as well as their perspectives about barriers and strategies for implementing the PRO-CTCAE in NCI-sponsored cancer trials, a survey was conducted. A survey including structured and open-ended questions was developed to elicit perceptions about the use of patient-reported outcomes (PROs) for adverse event reporting, and to explore logistical considerations for implementing the PRO-CTCAE in cancer trials. The survey was distributed electronically and by paper to a convenience sample of leadership and committee members in the NCI's cooperative group network, including principal investigators, clinical investigators, research nurses, data managers, patient advocates, and representatives of the NCI and Food and Drug Administration. Between October, 2008 through February, 2009, 727 surveys were collected. Most respondents (93%) agreed that patient reporting of adverse symptoms would be useful for improving understanding of the patient experience with treatment in cancer trials, and 88%, 80%, and 76%, respectively, endorsed that administration of PRO-CTCAE items in clinical trials would improve the completeness, accuracy, and efficiency of symptom data collection. More than three fourths believed that patient reports would be useful for informing treatment dose modifications and towards FDA regulatory evaluation of drugs. Eighty-eight percent felt that patients in clinical trials would be willing to self-report adverse symptoms at clinic visits via computer, and 68% felt patients would self-report weekly from home via the internet or an automated telephone system. Lack of computers and limited space and personnel were seen as potential barriers to in-clinic self-reporting, but these were judged to be surmountable with adequate funding. The PRO-CTCAE items and software are viewed by a majority of survey respondents as a means to improve adverse event data quality and comprehensiveness, enhance clinical decision-making, and foster patient-clinician communication. Research is ongoing to assess the measurement properties and feasibility of implementing this measure in cancer clinical trials.

Associations of cancer and other chronic medical conditions with SF-6D preference-based scores in Medicare beneficiaries

PURPOSE

Documenting the impact of different types of cancer on daily functioning and well-being is important for understanding burden relative to other chronic medical conditions. This study examined the impact of 10 different cancers and 13 other chronic medical conditions on health-related quality of life.

METHODS

Health-related quality of life data were gathered on the Medicare Health Outcomes Survey (MHOS) between 1998 and 2002. Cancer information was ascertained using the National Cancer Institute's surveillance, epidemiology, and end results program and linked to MHOS data.

RESULTS

The average SF-6D score was 0.73 (SD = 0.14). Depressive symptoms had the largest unique association with the SF-6D, followed by arthritis of the hip, chronic obstructive pulmonary disease/asthma, stroke, and sciatica. In addition, the majority of cancer types were significantly associated with the SF-6D score, with significant negative weights ranging from -0.01 to -0.02 on the 0-1 health utility scale. Distant stage of cancer was associated with large decrements in the SF-6D ranging from -0.04 (prostate) to -0.08 (female breast).

CONCLUSION

A large number of chronic conditions, including cancer, are associated uniquely with decrements in health utility. The cumulative effects of comorbid conditions have substantial impact on daily functioning and well-being of Medicare beneficiaries.

Cancer care coordination systematic review and meta-analysis: Twenty-two years of empirical studies

6536

Background: To our knowledge, no systematic review of empirical papers describing cancer care coordination interventions has yet been conducted. The aim of this presentation is to describe the methods and findings from a systematic review and meta-analysis of all empirical papers describing cancer care coordination published between 1990-2012. Methods: Of 1241 abstracts collected from a search of PubMed and EMBASE, 108 studies were retrieved and reviewed; 49 were included in the systematic review. Each study had US or Canadian adult or child participants; each paper had comparison or control groups, measures, samples, and/or interventions. Two researchers independently applied a standardized search strategy, coding scheme, and on-line coding program to each study. Eight RCT’s met additional criteria for meta-analysis; a random effects estimation model was used for data analysis. Results: Among the 49 articles included in our systematic review, those that included implicit or explicit definitions of cancer care coordination described four components: (1) roles and models for communication and transfer of care between primary care physicians and oncologists during active treatment and survivorship; (2) care navigation through designated personnel or telecommunication processes among care team members; (3) treatment summaries and survivorship care plans; and (4) multidisciplinary communication accompanying patient and practice management within the framework of the Chronic Care Model (N=14). We found a medium-sized effect of cancer care coordination on care usage outcomes among the randomized clinical trials (e.g., reduced Emergency Department visits; g = 0.37 [95% CI = 0.29 - 0.44], I2= .000. Fail-safe N = 86). Conclusions: The findings from this current systematic review and meta-analysis will contribute to the evidence base on strategies that can improve the coordination of cancer care, particularly for patients with multiple chronic conditions, and thereby advance the goals of health care reform in the US.

Utilizing QOPI in the quality improvement efforts of the NCI Community Cancer Centers Program (NCCCP)

208

Background: The NCCCP is a network of community based institutions from New England to Hawaii funded by the NCI. Quality of care is a priority of the NCCCP with participation in ASCO’s Quality Oncology Practice Initiative (QOPI) playing a fundamental role. QOPI provides a process for quality assessment but we have also used it as a measure of quality improvement (QI) network-wide. Using QOPI methodology, we have analyzed our performance twice a year in an effort to enhance our implementation of quality indicators relevant to program aims. Methods: A data sharing agreement allows individual practice QOPI data to be electronically sent to the NCI where it is aggregated with the other NCCCP QOPI participants. Data are presented via webinar within the network using a variety of QI strategies. For example, blinded site performance distributions are benchmarked against NCCCP national averages on specific indicators. High performing practices voluntarily present their QI initiatives and best practices to the network. The NCCCP Quality of Care Subcommittee then selects QI projects and areas to focus quality improvement efforts. Results: In Spring 2012, 44 practices affiliated with 25 NCCCP sites participated in QOPI, a consistent pattern since Fall 2010. The table below describes the percent compliance with certain QOPI measures for the NCCCP aggregate over time. Selected measures were perceived as having had suboptimal compliance in Fall 2010. Conclusions: QOPI is an effective tool for assessing quality within a network and for measuring quality improvement efforts. Best practices from within the network can be leveraged and disseminated to enhance the quality of cancer care. This methodology facilitates quality initiatives despite the logistical challenges of working with practices across the country. [Table: see text]

Evolution of multidisciplinary care: Experience of the National Cancer Institute (NCI) Community Cancer Centers Program (NCCCP)

67

Background: A key aim of the NCCCP is to develop and improve the quality of multidisciplinary care (MDC). An assessment tool with nine key elements relevant to MDC structure and operations was developed to assess MDC maturity and set goals for continued quality improvement at individual sites and across the network. Methods: 14 NCCCP sites self-reported MDC assessments for lung, breast, and colorectal cancer in June 2010, 2011, and 2012 using an online reporting tool. Each site evaluated their level of maturity (level 1 = no MDC, level 5 = highly integrated MDC) in nine elements integral to the MDC process. Qualitative review of sites’ responses was also conducted. Results: MDC improvement was most evident in four of nine elements; case planning (CP), physician engagement (PE), integration of care coordination (ICC), and quality improvement (QI). The number of sites at level 3 or greater is reported in the table below. Integration of primary care providers and increased organizational support contributed to improved CP. PE was related to conditions of participation, insuring involvement of appropriate physicians in the MDC. The network focus on patient navigation was demonstrated by increase of ICC. Improvement in QI was related to increased participation of sites in physician and hospital quality initiatives (i.e., QOPI and RQRS), and an NCCCP project aimed at increasing referrals to genetics for patient with breast and colon cancer. Conclusions: The maturity of MDC reflected focused work of the Quality of Care sub-committee of the NCCCP. The efforts of working groups in patient navigation, genetics and physician conditions of participation was made evident in the improved performance in MDC’s for three of the four most common malignancies seen in the United States. We hope that this work will provide a blueprint for other health systems that wish to incorporate multidisciplinary care into their cancer programs. [Table: see text]

In search of synergy: strategies for combining interventions at multiple levels

The social ecological perspective provides a compelling justification for multilevel intervention. Yet, it offers little guidance for selecting interventions that work together in complementary or synergistic ways. Using a causal modeling framework, we describe five strategies for increasing potential complementarity or synergy among interventions that operate at different levels of influence: accumulation, amplification, facilitation, cascade, and convergence. We illustrate these strategies with examples of multilevel interventions to improve the quality of cancer treatment.

Multilevel intervention research: lessons learned and pathways forward

This summary reflects on this monograph regarding multilevel intervention (MLI) research to 1) assess its added value; 2) discuss what has been learned to date about its challenges in cancer care delivery; and 3) identify specific ways to improve its scientific soundness, feasibility, policy relevance, and research agenda. The 12 submitted chapters, and discussion of them at the March 2011 multilevel meeting, were reviewed and discussed among the authors to elicit key findings and results addressing the questions raised at the outset of this effort. MLI research is underrepresented as an explicit focus in the cancer literature but may improve implementation of studies of cancer care delivery if they assess contextual, organizational, and environmental factors important to understanding behavioral and/or system-level interventions. The field lacks a single unifying theory, although several psychological or biological theories are useful, and an ecological model helps conceptualize and communicate interventions. MLI research designs are often complex, involving nonlinear and nonhierarchical relationships that may not be optimally studied in randomized designs. Simulation modeling and pilot studies may be necessary to evaluate MLI interventions. Measurement and evaluation of team and organizational interventions are especially needed in cancer care, as are attention to the context of health-care reform, eHealth technology, and genomics-based medicine. Future progress in MLI research requires greater attention to developing and supporting relevant metrics of level effects and interactions and evaluating MLI interventions. MLI research holds an unrealized promise for understanding how to improve cancer care delivery.

Multilevel research and the challenges of implementing genomic medicine

Advances in genomics and related fields promise a new era of personalized medicine in the cancer care continuum. Nevertheless, there are fundamental challenges in integrating genomic medicine into cancer practice. We explore how multilevel research can contribute to implementation of genomic medicine. We first review the rapidly developing scientific discoveries in this field and the paucity of current applications that are ready for implementation in clinical and public health programs. We then define a multidisciplinary translational research agenda for successful integration of genomic medicine into policy and practice and consider challenges for successful implementation. We illustrate the agenda using the example of Lynch syndrome testing in newly diagnosed cases of colorectal cancer and cascade testing in relatives. We synthesize existing information in a framework for future multilevel research for integrating genomic medicine into the cancer care continuum.

Multilevel interventions: measurement and measures

BACKGROUND

Multilevel intervention research holds the promise of more accurately representing real-life situations and, thus, with proper research design and measurement approaches, facilitating effective and efficient resolution of health-care system challenges. However, taking a multilevel approach to cancer care interventions creates both measurement challenges and opportunities.

METHODS

One-thousand seventy two cancer care articles from 2005 to 2010 were reviewed to examine the state of measurement in the multilevel intervention cancer care literature. Ultimately, 234 multilevel articles, 40 involving cancer care interventions, were identified. Additionally, literature from health services, social psychology, and organizational behavior was reviewed to identify measures that might be useful in multilevel intervention research.

RESULTS

The vast majority of measures used in multilevel cancer intervention studies were individual level measures. Group-, organization-, and community-level measures were rarely used. Discussion of the independence, validity, and reliability of measures was scant.

DISCUSSION

Measurement issues may be especially complex when conducting multilevel intervention research. Measurement considerations that are associated with multilevel intervention research include those related to independence, reliability, validity, sample size, and power. Furthermore, multilevel intervention research requires identification of key constructs and measures by level and consideration of interactions within and across levels. Thus, multilevel intervention research benefits from thoughtful theory-driven planning and design, an interdisciplinary approach, and mixed methods measurement and analysis.

Knowledge of energy balance guidelines and associated clinical care practices: the U.S. National Survey of Energy Balance Related Care among Primary Care Physicians

OBJECTIVE

To assess primary care physicians' (PCPs) knowledge of energy balance related guidelines and the association with sociodemographic characteristics and clinical care practices.

METHOD

As part of the 2008 U.S. nationally representative National Survey of Energy Balance Related Care among Primary Care Physicians (EB-PCP), 1776 PCPs from four specialties who treated adults (n=1060) or children and adolescents (n=716) completed surveys on sociodemographic information, knowledge of energy balance guidelines, and clinical care practices.

RESULTS

EB-PCP response rate was 64.5%. For PCPs treating children, knowledge of guidelines for healthy BMI percentile, physical activity, and fruit and vegetables intake was 36.5%, 27.0%, and 62.9%, respectively. For PCPs treating adults, knowledge of guidelines for overweight, obesity, physical activity, and fruit and vegetables intake was 81.4%, 81.3%, 70.9%, and 63.5%, respectively. Generally, younger, female physicians were more likely to exhibit correct knowledge. Knowledge of weight-related guidelines was associated with assessment of body mass index (BMI) and use of BMI-for-age growth charts.

CONCLUSION

Knowledge of energy balance guidelines among PCPs treating children is low, among PCPs treating adults it appeared high for overweight and obesity-related clinical guidelines and moderate for physical activity and diet, and was mostly unrelated to clinical practices among all PCPs.

Validation of the NCI patient-reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE) in women receiving treatment for metastatic breast cancer

9144

Background: NCI PRO-CTCAE is designed to enhance adverse event reporting by integrating patients’ self-report of the frequency (F), severity (S) and interference (I) with usual activities of 78 symptomatic treatment toxicities. This study examined the construct validity of a subset of PRO-CTCAE items in women with metastatic breast cancer (MBC). Methods: 207 women (70% aged 45-59 years; 94% White;71% college-educated) with HER2+ MBC who had received treatment in the past month were recruited from 6 U.S. breast cancer support groups and completed a web survey that collected 18 PRO-CTCAE symptoms, and the Rotterdam Symptom Checklist (RSC). Pairwise concordance among PRO-CTCAE symptom dimensions was examined using weighted Kappa and Bowker’s test for symmetry. Results: Respondents were a median of 47 months since MBC diagnosis and 61% rated their health-related quality of life (HRQL) as good to excellent. Symptom prevalence was similar for PRO-CTCAE and RSC, with respondents more likely to endorse mood disturbance on PRO-CTCAE (Anxiety/Worry 90%; Sad/Unhappy Feelings 86%) vs. RSC (Anxiety 63%; Depressed Mood 61%). There was parallel rank-ordering of fatigue, anxiety, insomnia, depression, difficulty concentrating and neuropathy as the symptoms that were most severe, interfered most and caused the greatest bother. Within PRO-CTCAE, pairwise agreement among F, S and I was moderate for most symptoms (κw=.42 to .54). Agreement between F and S was highest for pain, nausea and arm/leg swelling (κw=.61 to .80), and lowest for anxiety/worry and sad/unhappy feelings (κw= .27-.37). Except for arm/leg swelling, endorsement patterns by the dimensions of F, S and I were distinct (Bowker’s p all <.002). Across PRO-CTCAE symptoms, S was consistently higher than I (mean differences .12 to .72, all p<.01]). Means for S were consistently and significantly higher for those with impaired versus preserved HRQL, providing evidence of construct validity. Conclusions: This study supports the construct validity of PRO-CTCAE, and suggests that F, S and I dimensions offer non-overlapping information relative to 17 /18 PRO-CTCAE symptomatic toxicities.

Acceptability of the NCI patient-reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE) in women with metastatic breast cancer (MBC)

e19633

Background: NCI PRO-CTCAE is a new patient-reported outcome measure designed to enhance adverse event (AE) reporting in clinical trials by integrating the patient experience. The PRO-CTCAE item bank includes items representing the frequency (F), severity (S) and interference (I) with usual activities of 78 symptomatic AEs. The aim of this study was to examine the acceptability of a subset of PRO-CTCAE items to women receiving treatment for HER2+ MBC. Methods: 207 women on active treatment for HER2+ MBC (median 47 months since MBC diagnosis) were recruited from 6 U.S. breast cancer support groups and completed a web survey that included 18 PRO-CTCAE symptoms. Respondents were aged 45-64 years (71%), white (94%), college-educated (72%), with health-related quality of life rated good to excellent (61%) and median EQ5D utility score of 0.8. To explore PRO-CTCAE acceptability and data quality, we examined item level missingness, endorsement frequencies and binary and free-text responses about the comprehensibility of PRO-CTCAE items. Results: Item level missingness across all symptoms for each PRO-CTCAE dimension (F, S and I) ranged from 1.0% to 5.3%, with a median of 2.9%; interference associated with decreased appetite had the greatest missingness (5.3%). Excluding this outlier, maximum missingness was 3.9%. Endorsement frequencies of response choices for S of insomnia, constipation, fatigue, pain, anxiety/worry and sad/unhappy feelings support acceptable instrument sensitivity (all adjacent response points endorsed by >7% of respondents). Most respondents (92%) thought the items were easy to understand; a few were uncertain about how to rate symptoms such as anxiety, depression, insomnia and nausea if they were present but partially controlled with medication. Conclusions: These findings confirm and extend those of other studies demonstrating the acceptability of PRO-CTCAE. Evaluation in a more heterogeneous sample, particularly with respect to education and cancer site, is underway.

Fertility preservation: Utilizing QOPI metrics in the quality improvement efforts of the NCI Community Cancer Centers Program (NCCCP)

e16532

Background: The NCCCP is a consortium of 30 community based institutions funded by the NCI. Quality of care has been a priority of the NCCCP with participation in the Quality Oncology Practice Initiative (QOPI) serving as a fundamental element in those efforts. QOPI provides both a metric for baseline assessment and a means for measuring improvement across the network. Participation in QOPI became required with expansion of the NCCCP in 2010. Utilizing QOPI methodology, we describe our efforts to optimize adherence to fertility preservation standards of care. NCI Contract No. HHSN261200800001E Methods: A data sharing agreement allows individual practice performance to be electronically forwarded to the NCI twice a year where it is aggregated with the other NCCCP QOPI participants. This allows for ongoing evaluation of group statistics as well as comparisons between participating institutions. Those practices scoring highest on individual parameters are queried for best practices. Results: In Spring 2011, 38 practices/23 NCCCP sites participated resulting in 2653 chart reviews. 258 charts were applicable to fertile individuals as defined by QOPI. 46 charts were in compliance with suggested standards (17.8%) compared with the national rate of 26.1%. Four practices performed well above the national average and became the NCCCP's leaders for establishing best practices. The NCCCP then embarked upon a process of defining barriers to compliance with the fertility preservation recommendations, created an assessment tool by which each practice could identify the degree it integrated fertility preservation into their care models, and began the process of integrating nationally available educational materials and speakers. QOPI metrics will be used to measure the impact of these interventions. Conclusions: QOPI is a useful tool for measuring quality within a network, identifying barriers to compliance with ASCO fertility preservation recommendations and assessing quality improvement efforts. This methodology has allowed us to proceed with quality initiatives despite the logistical challenges of working with institutions and physicians from Maine to Hawaii.

Association of increases in quality of care with the NCI Community Cancer Center Program (NCCCP) pilot

6046

Background: The NCCCP pilot is an initiative designed to enhance research and improve cancer care at community hospitals. As part of a multi-method evaluation of this pilot, we assessed changes in quality of care among the 16 pilot NCCCP hospitals over time (before vs. after program initiation) and in comparison to a group of 25 similar hospitals that did not participate in the NCCCP. Methods: We compared changes in 5 NQF-approved quality of care measures (3 for breast cancer, 2 for colon cancer) from 2006/07 (before NCCCP initiation) vs. 2008/09/10 (post-initiation) for NCCCP and comparison group hospitals. Data were collected from all study hospitals using the Commission on Cancer’s Rapid Quality Reporting System, which allowed near real-time tracking of quality of care process measures. Results: Analyses included 18,608 breast cancer and 7,031 colon cancer patients. Patient-level concordance rates for all 5 quality of care measures increased significantly among both NCCCP and comparison group hospitals. The change (from baseline to post-NCCCP) in quality of care among NCCCP hospitals was significantly greater than the change among comparison group hospitals for two measures: radiation therapy following breast conserving surgery (RT-BCS) and hormonal therapy for women with hormone receptor positive breast cancer (HT). For the RT-BCS measure, NCCCP patients from underserved populations also experienced significantly greater changes in concordance than did corresponding populations from comparison group hospitals. In multivariate regression analyses controlling for patient characteristics, the change for the HT measure among NCCCP hospitals was significantly greater than that among comparison group hospitals. Conclusions: While both NCCCP and comparison group hospitals showed improved quality of care, participation in the NCCCP was associated with significantly greater improvements for a subset of measures. Including a separate comparison hospital group was critical for assessing changes associated with NCCCP participation while controlling for broader U.S. trends in improved quality of care. Future work will examine how hospital networks may have facilitated improvements in quality of care.

Validity and reliability of the patient-reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE)

9047

Background: Symptomatic adverse events (AE) in cancer trials are reported by clinicians using the National Cancer Institute's (NCI) Common Terminology Criteria for Adverse Events (CTCAE). To integrate the patient perspective into AE reporting, NCI contracted (HHSN261201000043C) to create a patient-reported outcomes companion tool (PRO-CTCAE). We report the validity and reliability of PRO-CTCAE’s 124 items reflecting 78 symptomatic AEs. Methods: English-speaking subjects (n=869; 44% male; median [mdn] age 59; 32% racial/ethnic minority; 34% high school or less; 17% ECOG Performance Status [PS] 2-4) receiving treatment for a range of cancers at 4 NCI-designated cancer centers and 5 sites in NCI's Community Cancer Centers Program completed a web-based survey in clinic including PRO-CTCAE and EORTC QLQ-C30. Pearson correlations were computed between PRO-CTCAE items and QLQ-C30 scales. Differences in PRO-CTCAE item scores between clinician-reported ECOG PS (0-1 vs 2-4) groups were computed. Test-retest reliability of 48 prespecified items was evaluated in a subset (n=79). Results: Correlations in the expected direction were observed for 116/124 PRO-CTCAE items with the QLQ-C30 global health scale (mdn r=-.21; range .08 to -.57). Stronger correlations were seen for PRO-CTCAE items with conceptually related QLQ-C30 domains: fatigue with physical, role and social functioning (-.54 to -.66); anxiety and depression with emotional functioning (-.54 to -.70); and concentration and memory problems with cognitive functioning (-.62 to -.72) [all p <0.001]. Fatigue, nausea, vomiting, pain, dyspnea, insomnia, appetite loss, constipation and diarrhea items strongly correlated with corresponding QLQ-C30 symptom scales (.69 to .79, all p <0.001). Scores for 98/124 PRO-CTCAE items were higher in the ECOG PS 2-4 vs 0-1 group (mdn effect size .3). Test-retest reliability was observed across all tested items (mdn intraclass correlation coeff .77; range .53 to .96). Conclusions: Results demonstrate favorable validity and reliability of PRO-CTCAE in a large, heterogeneous sample of patients undergoing cancer treatment. Further testing in multicenter treatment trials is underway.

The NCI Community Cancer Centers Program (NCCCP): A model for reducing cancer health care disparities

6086

Background: In 2007, NCI launched the NCCCP, a public-private partnership with 16 community hospital cancer centers in 14 states, to explore methods to improve patient access to advanced cancer care in the community. With 40% of its NCI funding directed to reduce disparities across the cancer continuum, the NCCCP aims to: 1) Enhance access to care; 2) Improve quality of care; and 3) Increase clinical trials accrual. This approach supports priorities in the 2009 ASCO Policy Statement: Disparities in Cancer Care. Methods: A disparities workplan was developed to support the three aims. NCI and the sites worked as a learning collaborative to develop strategies and metrics for: race and ethnicity data tracking; near real-time reporting of adherence to Commission on Cancer (CoC) treatment quality measures; community outreach and patient navigation to increase cancer screening; and improved clinical trial underserved accrual. The tools and resources supporting these efforts will be discussed. ( http://ncccp.cancer.gov/About/Progress.htm ). Results: Evaluation of the 3 year pilot shows improvement for underserved populations: Concordance with CoC treatment quality measures for radiation therapy for breast conserving surgery among Medicaid patients improved from 59.5 percent to 84.8 percent (p<.05). Increased community screening events (from 992 to 1,585) and community partnerships focused on underserved populations (from 78 to 195). Increased accrual to NCI trials (minority accrual from 82 to 151 and elderly from 200 to 641). Conclusions: To be effective in reducing healthcare disparities, a multi-level approach is needed. This includes having: organizations which demonstrate a strong community-oriented mission; commitment by hospital management; engagement of private practice physicians; targeted training of staff; use of standardized data collection and metrics; involvement of strategic partners with aligned goals at the national and local level; support by relevant NCI experts; and sharing best practices across a learning collaborative. The NCCCP disparities model was used in a variety of community settings targeting different underserved populations and has demonstrated effect in care in the respective communities.

Introduction: Understanding and influencing multilevel factors across the cancer care continuum

Health care in the United States is notoriously expensive while often failing to deliver the care recommended in published guidelines. There is, therefore, a need to consider our approach to health-care delivery. Cancer care is a good example for consideration because it spans the continuum of health-care issues from primary prevention through long-term survival and end-of-life care. In this monograph, we emphasize that health-care delivery occurs in a multilevel system that includes organizations, teams, and individuals. To achieve health-care delivery consistent with the Institute of Medicine's six quality aims (safety, effectiveness, timeliness, efficiency, patient-centeredness, and equity), we must influence multiple levels of that multilevel system. The notion that multiple levels of contextual influence affect behaviors through interdependent interactions is a well-established ecological view. This view has been used to analyze health-care delivery and health disparities. However, experience considering multilevel interventions in health care is much less robust. This monograph includes 13 chapters relevant to expanding the foundation of research for multilevel interventions in health-care delivery. Subjects include clinical cases of multilevel thinking in health-care delivery, the state of knowledge regarding multilevel interventions, study design and measurement considerations, methods for combining interventions, time as a consideration in the evaluation of effects, measurement of effects, simulations, application of multilevel thinking to health-care systems and disparities, and implementation of the Affordable Care Act of 2010. Our goal is to outline an agenda to proceed with multilevel intervention research, not because it guarantees improvement in our current approach to health care, but because ignoring the complexity of the multilevel environment in which care occurs has not achieved the desired improvements in care quality outlined by the Institute of Medicine at the turn of the millennium.

Impact of diagnosis and treatment of clinically localized prostate cancer on health-related quality of life for older Americans: a population-based study

BACKGROUND

Few studies have measured longitudinal changes in health-related quality of life (HRQOL) among patients with prostate cancer starting before their cancer diagnosis or have provided simultaneous comparisons with a matched noncancer cohort. In the current study, the authors addressed these gaps by providing unique estimates of the effects of a cancer diagnosis on HRQOL accounting for the confounding effects of ageing and comorbidity.

METHODS

Data from the Surveillance, Epidemiology, and End Results registry were linked with Medicare Health Outcomes Survey (MHOS) data. Eligible patients (n = 445) were Medicare beneficiaries aged ≥65 years from 1998 to 2003 whose first prostate cancer diagnosis occurred between their baseline and follow-up MHOS. By using propensity score matching, 2225 participants without cancer were identified from the MHOS data. Analysis of covariance models were used to estimate changes in HRQOL as assessed with the Medical Outcomes Study Short Form-36 survey and the activities of daily living scale.

RESULTS

Before diagnosis, patients with prostate cancer reported HRQOL similar to that of men without cancer. After diagnosis, men with prostate cancer experienced significant decrements in physical, mental, and social aspects of their lives relative to controls, especially within the first 6 months after diagnosis. For men who were surveyed beyond 1 year after diagnosis, HRQOL was similar to that for controls. However, an increased risk for major depressive disorder was observed among men who received either conservative management or external beam radiation.

CONCLUSIONS

The current findings illustrated the time-sensitive nature of decline in HRQOL after a cancer diagnosis and enhanced understanding of the impact of prostate cancer diagnosis and treatment on physical, mental, and social well being among older men.

Systems strategies to support cancer screening in U.S. primary care practice

BACKGROUND

Although systems strategies are effective in improving health care delivery, little is known about their use for cancer screening in U.S. primary care practice.

METHODS

We assessed primary care physicians' (N = 2,475) use of systems strategies for breast, cervical, and colorectal cancer (CRC) screening in a national survey conducted in 2007. Systems strategies included patient and physician screening reminders, performance reports of screening rates, electronic medical records, implementation of in-practice guidelines, and use of nurse practitioners/physician assistants. We evaluated use of both patient and physician screening reminders with other strategies in separate models by screening type, adjusted for the effects of physician and practice characteristics with multivariate logistic regression.

RESULTS

Fewer than 10% of physicians used a comprehensive set of systems strategies to support cancer screening; use was greater for mammography and Pap testing than for CRC screening. In adjusted analyses, performance reports of cancer screening rates, medical record type, and in-practice guidelines were associated with use of both patient and physician screening reminders for mammography, Pap testing, and CRC screening (P < 0.05).

CONCLUSION

Despite evidence supporting use of systems strategies in primary care, few physicians report using a comprehensive set of strategies to support cancer screening.

IMPACT

Current health policy initiatives underscore the importance of increased implementation of systems strategies in primary care to improve the use and quality of cancer screening in the United States.

Physicians' attitudes about communicating and managing scientific uncertainty differ by perceived ambiguity aversion of their patients

BACKGROUND

Medical interventions are often characterized by substantial scientific uncertainty regarding their benefits and harms. Physicians must communicate to their patients as part of the process of shared decision making, yet they may not always communicate scientific uncertainty for several reasons. One suggested by past research is individual differences in physicians' tolerance of uncertainty. Relatedly, an unexplored explanation is physicians' beliefs about their patients' tolerance of uncertainty.

DESIGN

To test this possibility, we surveyed a sample of primary care physicians (N = 1500) and examined the association between their attitudes about communicating and managing scientific uncertainty and their perceptions of negative reactions to uncertainty by their patients. Physician perceptions were measured by their propensity towards pessimistic appraisals of risk information and avoidance of decision making when risk information is ambiguous--of uncertain reliability, credibility or adequacy, known as 'ambiguity aversion'.

RESULTS

Confirming past studies, physician demographics (e.g. medical specialty) predicted attitudes toward communicating scientific uncertainty. Additionally, physicians' beliefs about their patients' ambiguity aversion significantly predicted these preferences. Physicians who thought that more of their patients would have negative reactions to ambiguous information were more likely to think that they should decide what is best for their patients (β = 0.065, P = 0.013), and to withhold an intervention that had uncertainty associated with it (β = 0.170, P < 0.001).

DISCUSSION

When faced with the task of communicating scientific uncertainty about medical tests and treatments, physicians' perceptions of their patients' ambiguity aversion may be related to their attitudes towards communicating uncertainty.

Population sciences, translational research, and the opportunities and challenges for genomics to reduce the burden of cancer in the 21st century

Advances in genomics and related fields are promising tools for risk assessment, early detection, and targeted therapies across the entire cancer care continuum. In this commentary, we submit that this promise cannot be fulfilled without an enhanced translational genomics research agenda firmly rooted in the population sciences. Population sciences include multiple disciplines that are needed throughout the translational research continuum. For example, epidemiologic studies are needed not only to accelerate genomic discoveries and new biological insights into cancer etiology and pathogenesis, but to characterize and critically evaluate these discoveries in well-defined populations for their potential for cancer prediction, prevention and response to treatment. Behavioral, social, and communication sciences are needed to explore genomic-modulated responses to old and new behavioral interventions, adherence to therapies, decision making across the continuum, and effective use in health care. Implementation science, health services, outcomes research, comparative effectiveness research, and regulatory science are needed for moving validated genomic applications into practice and for measuring their effectiveness, cost-effectiveness, and unintended consequences. Knowledge synthesis, evidence reviews, and economic modeling of the effects of promising genomic applications will facilitate policy decisions and evidence-based recommendations. Several independent and multidisciplinary panels have recently made specific recommendations for enhanced research and policy infrastructure to inform clinical and population research for moving genomic innovations into the cancer care continuum. An enhanced translational genomics and population sciences agenda is urgently needed to fulfill the promise of genomics in reducing the burden of cancer.