Determinants of targeted cancer therapy use in community oncology practice: a qualitative study using the Theoretical Domains Framework and Rummler-Brache process mapping

BACKGROUND

Precision medicine holds enormous potential to improve outcomes for cancer patients, offering improved rates of cancer control and quality of life. Not all patients who could benefit from targeted cancer therapy receive it, and some who may not benefit do receive targeted therapy. We sought to comprehensively identify determinants of targeted therapy use among community oncology programs, where most cancer patients receive their care.

METHODS

Guided by the Theoretical Domains Framework, we conducted semi-structured interviews with 24 community cancer care providers and mapped targeted therapy delivery across 11 cancer care delivery teams using a Rummler-Brache diagram. Transcripts were coded to the framework using template analysis, and inductive coding was used to identify key behaviors. Coding was revised until a consensus was reached.

RESULTS

Intention to deliver precision medicine was high across all participants interviewed, who also reported untenable knowledge demands. We identified distinctly different teams, processes, and determinants for (1) genomic test ordering and (2) delivery of targeted therapies. A key determinant of molecular testing was role alignment. The dominant expectation for oncologists to order and interpret genomic tests is at odds with their role as treatment decision-makers' and pathologists' typical role to stage tumors. Programs in which pathologists considered genomic test ordering as part of their staging responsibilities reported high and timely testing rates. Determinants of treatment delivery were contingent on resources and ability to offset delivery costs, which low- volume programs could not do. Rural programs faced additional treatment delivery challenges.

CONCLUSIONS

We identified novel determinants of targeted therapy delivery that potentially could be addressed through role re-alignment. Standardized, pathology-initiated genomic testing may prove fruitful in ensuring patients eligible for targeted therapy are identified, even if the care they need cannot be delivered at small and rural sites which may have distinct challenges in treatment delivery. Incorporating behavior specification and Rummler-Brache process mapping with determinant analysis may extend its usefulness beyond the identification of the need for contextual adaptation.

Comparison of Older and Younger Patients Referred to a Non-interventional Community Pain Clinic in the Greater Toronto Area (GTA)

AIM

To compare demographic and pain characteristics of older (≥ 65) vs younger (< 65) chronic non-cancer pain patients referred to a community pain clinic in the Greater Toronto Area (GTA), Ontario, Canada.

METHODS

This is a retrospective study of 644 consecutive new patients with pain seen during 2016-2017 (older group n = 126; younger group n = 518). Demographic characteristics, Brief Pain Inventory pain ratings, and diagnosis were obtained using retrospective chart review. Patients were classified into group I (pure biomedical pathology), group II (mixed biomedical causes and psychological factors) and group III (no detectable physical pathology but psychological factors were considered important).

RESULTS

Older patients comprised 19.6% of the overall population (higher than the average GTA older population). Regarding older vs younger group, male/female ratio was 1:1.3 vs 1:1.7 respectively, while 71% of the older patients were foreign born vs 37% of the younger group (p < 0.001). Low back was the most prevalent pain site for both groups; 70% of the older patients were classified as group I vs 35% of the younger patients (p < 0.0001), and only 6% as group III (vs 18% of the younger population, p < 0.05).

CONCLUSION

The study points to considerable differences between younger and older patients with pain with the latter presenting with significant biomedical pathology but lesser psychopathology. The results are comparable to those obtained from a university pain clinic as well as a rural Northern Ontario clinic. Implications of the study for planning of pain care are discussed.

Demographics, Pain Characteristics and Diagnostic Classification Profile of Chronic Non-Cancer Pain Patients Attending a Canadian University-Affiliated Community Pain Clinic

INTRODUCTION

Little information exists regarding the characteristics of patients with chronic non-cancer pain (CNCP) attending Canadian pain clinics. The study describes the demographics, pain characteristics and the diagnostic classification profile of such patients attending a university-affiliated community-based pain clinic in the Greater Toronto Area.

METHODS

Retrospective descriptive study based on 644 unique consecutive CNCP patients assessed between January 2016 and December 2017.

RESULTS

The female/male ratio was 1.6:1; 80% were younger than 65 years; 43% held some form of employment (full-time, part-time or self employment); median pain duration was 3 years; car accidents and medical conditions accounted for 28 and 27% of pain onset, respectively; 34% had four or more distinct areas of pain; and low back pain (LBP) was the most prevalent site (66%), but was the sole site of pain in less than a third of these patients. Age was positively associated with LBP prevalence. Self-reported health service utilization (visits to the emergency room, pain physician or psychologist) increased with patient psychopathology. Cannabis was used by 15% of the cohort and opioids by 34.5%, with only one in six opioid users exceeding 90 mg of morphine equivalent dose per day. Comparison of our data to three previously published studies from other Canadian pain clinics demonstrated both similarities and substantial differences between the populations.

CONCLUSION

Our study highlights regional differences between CNCP population phenotypes. Recognition of biomedical, psychological and socio-environmental factors affecting pain should be considered for patient stratification and rational approaches to treatment, as "one size treatment does not fit all".

Multi-component cognitive intervention for older adults with mixed cognitive levels: implementation and preliminary effectiveness in real-world settings

BACKGROUND

In most controlled studies of multi-component cognitive intervention, participants' cognitive levels are homogenous, which is contrary to real-world settings. There is a lack of research studying the implementation of evidence-based cognitive intervention in communities. This study describes the implementation and preliminary effectiveness of a Multi-component Cognitive Intervention using Simulated Everyday Tasks (MCI-SET) for older adults with different cognitive levels in real-world settings.

METHODS

Single group, pre-intervention assessment, post-intervention assessment, and 3-month follow-up research design. MCI-SET consists of 12 two-hour weekly sessions that include motor-cognitive tasks, cognitive training, and cognitive rehabilitation. One hundred and thirty participants, > = 65 and frail, dependence on > = one instrumental daily activity, or with confirmed dementia, from eight community centers were included. The primary outcome is general cognition (Montreal Cognitive Assessment-Taiwan, MoCA-T). Secondary outcomes are memory (Miami Prospective Memory Test, Digits Forward, Digits Backward), attention (Color Trail Test-Part 1), executive function (Color Trail Test-Part 2), and general function (Kihon Checklist-Taiwan).

RESULTS

Pre-intervention workshop for group leaders, standardized activity protocols, on-site observation, and ten weekly conferences were conducted to ensure implementation fidelity. MCI-SET had an 85% retention rate and 96% attendance rate. The participants had a mean age of 78.26 ± 7.00 and a mean MoCA-T score of 12.55 ± 7.43. 73% were female. General cognition (Hedges' g = 0.31), attention (Hedges' g = 0.23), and general function (Hedges' g = 0.31), showed significant post-intervention improvement with small effect size. Follow-ups showed maintained improvement in general cognition (Hedges' g = 0.33), and delayed effect on attention (Hedges' g = 0.20), short-term memory (Hedges' g = 0.38), and executive function (Hedges' g = 0.40). Regression analysis indicated that the intervention settings (day care centers vs neighborhood centers), the pre-intervention cognitive levels, and the pre-intervention general function of the participants were not associated with the outcomes.

CONCLUSIONS

MCI-SET is feasible and can improve the cognitive skills and general functions of older adults with heterogeneous cognitive skills or disabilities. It is essential to tailor programs to fit the interests of the participants and the culture of local communities. Group leaders must also have the skills to adjust the cognitive demands of the tasks to meet the heterogeneous cognitive levels of participants.

TRIAL REGISTRATION

This study was retrospectively registered at clinicaltrials.gov (Identifier: NCT04615169 ).

Health-related quality of life changes after the merging yoga and occupational therapy for Parkinson's disease program: A mixed-methods study

BACKGROUND

To understand changes in health-related quality of life (HRQoL) after the Merging Yoga and Occupational Therapy for Parkinson's Disease (MY-OT for PD) program.

MATERIALS AND METHODS

We used a mixed-methods convergent design and administered the Parkinson's Disease Questionnaire-8 (PDQ-8), a measure of HRQoL, with 17 participants. We considered scores 8 weeks before MY-OT for PD, just before, and upon completion. Additionally, we completed two focus groups following the program with 16 participants to assess qualitative changes in HRQoL.

RESULTS

There were no significant differences in PDQ-8 scores between time points, F(2,32) = 1.60, p = 0.22, partial η² = 0.09. Participants did discuss improvements in all 8 HRQoL domains, frequently regarding mobility and activities of daily living.

CONCLUSION

Results diverged, with quantitative results showing no significant improvement in HRQoL and qualitative results indicating participant perceived improvements in all domains of the PDQ-8. The program should be explored further, and longitudinal follow-up completed.

It takes a village: a realist synthesis of social pediatrics program

OBJECTIVES

To better understand how social pediatric initiatives (SPIs) enact equitable, integrated, embedded approaches with high-needs children and families while facilitating proportionate distribution of health resources.

METHODS

The realist review method incorporated the following steps: (1) identifying the review question, (2) formulating the initial theory, (3) searching for primary studies, (4) selecting and appraising study quality, (5) synthesizing relevant data and (6) refining the theory.

RESULTS

Our analysis identified four consistent patterns of care that may be effective in social pediatrics: (1) horizontal partnerships based on willingness to share status and power; (2) bridged trust initiated through previously established third party relationships; (3) knowledge support increasing providers' confidence and skills for engaging community; and (4) increasing vulnerable families' self-reliance through empowerment strategies.

CONCLUSIONS

This research is unique because it focused on "how" outcomes are achieved and offers insight into the knowledge, skills and philosophical orientation clinicians need to effectively deliver care in SPIs. Research insights offer guidance for organizational leaders with a mandate to address child and youth health inequities and may be applicable to other health initiatives.

Outcomes and impact of community-based rehabilitation programmes in Chinese communities

PURPOSE

To identify the most common and most valued outcomes of community-based rehabilitation (CBR) in Chinese communities and to map these to the CBR evaluation framework.

METHOD

A multiple, embedded case study design was used. Four CBR programmes in China met the criteria for inclusion and participated. Data collection, via participant "story telling", followed the procedures of the most significant change technique (MSC) over a period for five months. Content analysis with thematic coding was used to detect the common significant changes described in "top-rated" stories and in the entire pool of stories. Meta-analysis using the CBR framework was carried out to enrich the understanding of programme outcomes.

RESULTS

A total of 101 stories were collected in the two rounds of story collection from the four programmes. Aggregated results demonstrated that, across all programmes, 78.21% of stories focused on changes in people with disabilities, 9.9% described aspects of programme development, 8.91% reported on outcomes related to CBR workers, and only 2.97% were focused on advocacy. When mapped against the elements of the CBR framework the MSCs among these four programmes were (1) psychosocial changes, (2) increased family participation and (3) improved physical functioning.

CONCLUSIONS

CBR practice in Chinese communities remains orientated towards an approach of functional rehabilitation rather than community-based inclusive development. Implications for rehabilitation Community-based rehabilitation is a strategy for community-based inclusive development. Commonly reported significant outcomes of community-based rehabilitation programmes in China focus on changes in psychosocial and physical status of people with disabilities and family participation. Community-based rehabilitation in China continues to focus on traditional rehabilitation. New efforts and directions are needed to also include goals of equity and community inclusion. Further efforts to promote the use of CBR guideline with the goal of facilitating inclusion and equal participation are strongly recommended.

A Scholarship of Practice Revisited: Creating Community-Engaged Occupational Therapy Practitioners, Educators, and Scholars

Trends in policy, practice, and research point to the need for a community-engaged Scholarship of Practice (SOP) model that can be used to inform the development of occupational therapy practitioners, educators, and researchers. This article describes a community-engaged SOP model, the evidence justifying the need for such a model, and strategies to effectively create community-engaged practitioners, educators and career scientists within occupational therapy. We highlight several examples of community-based participatory research to further inform this model, and in turn, translate this knowledge back to communities for action and systems change that can affect the lives of people with disabilities and the communities in which they seek to live and participate long term.

Role of occupational therapy in promoting self-determination through consumer-directed supports

Consumer-directed services (CDS) are a type of support system designed to increase the quality of life and self-determination of clients, such as adults with developmental disabilities. Occupational therapists can play an important role in facilitating people's involvement in CDS supports. This paper describes CDS, evidence that supports their use, and ways that occupational therapists use their training in person-centered practice to enhance CDS supports and self-determination. A case study is used to illustrate the application.