Perspectives on the Intersection of Electronic Health Records and Health Care Team Communication, Function, and Well-being.

Importance: Understanding of the interplay between the electronic health record (EHR), health care team relations, and physician well-being is currently lacking. Approaches to cultivate interpersonal interactions may be necessary to complement advancements in health information technology with high-quality team function. Objective: To examine ways in which the EHR, health care team functioning, and physician well-being intersect and interact. Design, Setting, and Participants: Secondary qualitative analysis of semistructured interview data from 2 studies used keyword-in-context approaches to identify excerpts related to teams. Thematic analysis was conducted using pattern coding, then organized using the relationship-centered organization model. Two health care organizations in California from March 16 to October 13, 2017, and February 28 to April 21, 2022, participated, with respondents including attending and resident physicians. Main Outcome and Measures: Across data sets, themes centered around the interactions between the EHR, health care team functioning, and physician well-being. The first study data focused on EHR-related distressing events and their role in attending physician and resident physician emotions and actions. The second study focused on EHR use and daily EHR irritants. Results: The 73 respondents included attending physicians (53 [73%]) and resident physicians (20 [27%]). Demographic data were not collected. Participants worked in ambulatory specialties (33 [45%]), hospital medicine (10 [14%]), and surgery (10 [14%]). The EHR was reported to be the dominant communication modality among all teams. Interviewees indicated that the EHR facilitates task-related communication and is well suited to completing simple, uncomplicated tasks. However, EHR-based communication limited the rich communication and social connection required for building relationships and navigating conflict. The EHR was found to negatively impact team function by promoting disagreement and introducing areas of conflict into team relationships related to medical-legal pressures, role confusion, and undefined norms around EHR-related communication. In addition, interviewees expressed that physician EHR-related distress affects interactions within the team, eroding team well-being. Conclusions and Relevance: In this study, the EHR supported task-oriented and efficient communication among team members to get work done and care for patients; however, participants felt that the technology shifts attention away from the human needs of the care team that are necessary for developing relationships, building trust, and resolving conflicts. Interventions to cultivate interpersonal interactions and team function are necessary to complement the efficiency benefits of health information technology.

Factors Associated with the Breast Cancer Diagnostic Interval across Five Canadian Provinces: A CanIMPACT Retrospective Cohort Study.

The cancer diagnostic process can be protracted, and it is a time of great anxiety for patients. The objective of this study was to examine inter- and intra-provincial variation in diagnostic intervals and explore factors related to the variation. This was a multi-province retrospective cohort study using linked administrative health databases. All females with a diagnosis of histologically confirmed invasive breast cancer in British Columbia (2007-2010), Manitoba (2007-2011), Ontario (2007-2010), Nova Scotia (2007-2012), and Alberta (2004-2010) were included. The start of the diagnostic interval was determined using algorithms specific to whether the patient's cancer was detected through screening. We used multivariable quantile regression analyses to assess the association between demographic, clinical and healthcare utilization factors with the diagnostic interval outcome. We found significant inter- and intra-provincial variation in the breast cancer diagnostic interval and by screen-detection status; patients who presented symptomatically had longer intervals than screen-detected patients. Interprovincial diagnostic interval variation was 17 and 16 days for screen- and symptom-detected patients, respectively, at the median, and 14 and 41 days, respectively, at the 90th percentile. There was an association of longer diagnostic intervals with increasing comorbid disease in all provinces in non-screen-detected patients but not screen-detected. Longer intervals were observed across most provinces in screen-detected patients living in rural areas. Having a regular primary care provider was not associated with a shorter diagnostic interval. Our results highlight important findings regarding the length of the breast cancer diagnostic interval, its variation within and across provinces, and its association with comorbid disease and rurality. We conclude that diagnostic processes can be context specific, and more attention should be paid to developing tailored processes so that equitable access to a timely diagnosis can be achieved.

"Never waste a good crisis": A qualitative study of the impact of COVID-19 on palliative care in seven hospitals using the Dynamic Sustainability Framework.

BACKGROUND: The COVID-19 pandemic led to rapid adaptations among palliative care services, but it is unclear how these adaptations vary in relation to their unique organizational contexts. AIM: Understand how the pandemic impacted the implementation of new and existing palliative care programs in diverse hospital systems using the Dynamic Sustainability Framework. DESIGN: Twelve in-depth interviews with 15 key informants representing palliative care programs from seven hospital systems between April and June 2020. SETTING: Public, not-for-profit private, community, and academic teaching hospitals in the San Francisco Bay Area with existing palliative care programs that were expanding services to new clinical areas (e.g. new outpatient clinic or community-based care). RESULTS: Six themes characterized how palliative care programs were impacted and adapted during the early stages of the COVID-19 pandemic: palliative care involvement in preparing for surge, increased emphasis on advance care planning, advocating for visitors for dying patients, providing emotional support to clinicians, adopting virtual approaches to care, and gaps in chaplaincy support. There was variation in how new and existing programs were able to adapt to early pandemic stresses; systems with new outpatient programs struggled to utilize their programs effectively during the crisis onset. CONCLUSIONS: The fit between palliative care programs and practice setting was critical to program resiliency during the early stages of the pandemic. Reconceptualizing the Dynamic Sustainability Framework to reflect a bidirectional relationship between ecological system, practice setting, and intervention levels might better guide implementers and researchers in understanding how ecological/macro changes can influence interventions on the ground.

Characterizing patient flow after an academic hospital merger and acquisition.

OBJECTIVES: Hospital mergers and acquisitions are increasingly used as a strategy to facilitate value-based care. However, no studies have assessed health care utilization (HCU) and patient flow across merged institutions. We aim to evaluate patient population distribution, HCU, and patient flow across a recent hospital merger of an academic medical center (AMC), a primary and specialty care alliance (PSC), and a community-based medical center (CMC). STUDY DESIGN: This was a retrospective observational study. METHODS: The study used 2018 adult demographic and encounter data from electronic health records. Patients' parent health care institution was determined by the most frequently visited site of face-to-face visits. Differences in patient demographics and HCU (ie, emergency department [ED] visits, hospitalizations, primary care visits) were compared. Independent factors associated with utilization were identified using adjusted logistic regression models. RESULTS: A total of 406,303 adult patients were identified in the cohort. The PSC setting, compared with the AMC and the CMC, had significantly more female (62.7% vs 54.4% and 58.5%, respectively), older (mean [SD] age, 52.0 [18.1] vs 51.1 [17.8] and 49.2 [17.8] years), and privately insured (63.6% vs 51.3% and 56.0%) patients. A higher proportion of patients at the CMC (27.5%) visited the ED compared with patients at the AMC (10.8%). Approximately 1645 primary care patients (7%) at the CMC setting went to the AMC for specialized care such as oncology, surgery, and neurology. CONCLUSIONS: Hospital mergers are increasing across the United States, allowing AMCs to expand their reach. These findings suggest that patients mainly sought care at their parent health care institution, yet appropriately received specialized care at the AMC. These results provide insights for future mergers and guide resource allocation and opportunities for improving care delivery.

Patient and surgeon experiences with video visits in plastic surgery-toward a data-informed scheduling triage tool.

BACKGROUND: Coronavirus disease 2019 provided the impetus for unprecedented adoption of telemedicine. This study aimed to understand video visit adoption by plastic surgery providers; and patient and surgeon perceptions about its efficacy, value, accessibility, and long-term viability. A secondary aim was to develop the proposed 'Triage Tool for Video Visits in Plastic Surgery' to help determine visit video eligibility. METHODS: This mixed-methods evaluation assessed provider-level scheduling data from the Division of Plastic and Reconstructive Surgery at Stanford Health Care to quantify telemedicine adoption and semi-structured phone interviews with patients (n = 20) and surgeons (n = 10) to explore stakeholder perspectives on video visits. RESULTS: During the 13-week period after the local stay-at-home orders due to coronavirus disease 2019, 21.4% of preoperative visits and 45.5% of postoperative visits were performed via video. Video visits were considered acceptable by patients and surgeons in plastic surgery in terms of quality of care but were limited by the inability to perform a physical examination. Interviewed clinicians reported that long-term viability needs to be centered around technology (eg, connection, video quality, etc) and physical examinations. Our findings informed a proposed triage tool to determine the appropriateness of video visits for individual patients that incorporates visit type, anesthesia, case, surgeon's role, and patient characteristics. CONCLUSION: Video technology has the potential to facilitate and improve preoperative and postoperative patient care in plastic surgery but the following components are needed: patient education on taking high-quality photos; standardized clinical guidelines for conducting video visits; and an algorithm-assisted triage tool to support scheduling.

"Along for the Ride": A Qualitative Study Exploring Patient and Caregiver Perceptions of Decision Making in Cancer Care.

Background. Shared decision making is a cornerstone of an informed consent process for cancer treatment, yet there are often many physician and patient-related barriers to participation in the process. Decisions in cancer care are often perceived as relating to a discrete, treatment decision event, yet there is evidence that decisions are longitudinal in nature and reflect a multifactorial experience. Objective. To explore patient and caregiver perceptions of the choices and decision-making opportunities within cancer care. Design. Qualitative in-depth interviews with 37 cancer patients and 7 caregivers carried out as part of an evaluation of a cancer center's effort to improve patient experience. Results. Participants described decision making related to four distinct phases in complex cancer care, with physicians leading, and often limiting, decisions related to disease assessment and treatment options and access, and patients leading decisions related to physician selection. Though physicians led many decisions, patients had a moderating influence on treatment, such that if patients did not like options presented, they would reconsider their options and sometimes switch physicians. Patients had various strategies for dealing with uncertainty when faced with decisions, such as seeking additional information to make an informed choice or making a conscious choice to defer decision making to the physician. Limitations. Patients were sampled from one academic cancer center that serves a predominantly Caucasian, Asian, and Hispanic/Latino population and received complex treatment. Conclusion. Because of the complexity of cancer treatment, many patients felt as though they were a "passenger" in decision making about care and did not lead many of the decisions, though many patients trusted their doctors to make the best decisions and were comforted by their expertise.

The Stanford Lightning Report Method: A comparison of rapid qualitative synthesis results across four implementation evaluations.

BACKGROUND: Current evaluation methods are mismatched with the speed of health care innovation and needs of health care delivery partners. We introduce a qualitative approach called the lightning report method and its specific product-the "Lightning Report." We compare implementation evaluation results across four projects to explore report sensitivity and the potential depth and breadth of lightning report method findings. METHODS: The lightning report method was refined over 2.5 years across four projects: team-based primary care, cancer center transformation, precision health in primary care, and a national life-sustaining decisions initiative. The novelty of the lightning report method is the application of Plus/Delta/Insight debriefing to dynamic implementation evaluation. This analytic structure captures Plus ("what works"), Delta ("what needs to be changed"), and Insights (participant or evaluator insights, ideas, and recommendations). We used structured coding based on implementation science barriers and facilitators outlined in the Consolidated Framework for Implementation Research (CFIR) applied to 17 Lightning Reports from four projects. RESULTS: Health care partners reported that Lighting Reports were valuable, easy to understand, and they implied reports supported "corrective action" for implementations. Comparative analysis revealed cross-project emphasis on the domains of Inner Setting and Intervention Characteristics, with themes of communication, resources/staffing, feedback/reflection, alignment with simultaneous interventions and traditional care, and team cohesion. In three of the four assessed projects, the largest proportion of coding was to the clinic-level domain of Inner Setting-ranging from 39% for the cancer center project to a high of 56% for the life-sustaining decisions project. CONCLUSIONS: The lightning report method can fill a gap in rapid qualitative approaches and is generalizable with consistent but flexible core methods. Comparative analysis suggests it is a sensitive tool, capable of uncovering differences and insights in implementation across projects. The Lightning Report facilitates partnered evaluation and communication with stakeholders by providing real-time, actionable insights in dynamic health care implementations.

Inter- and intra-provincial variation in screen-detected breast cancer across five Canadian provinces: a CanIMPACT study.

OBJECTIVE: Breast cancer screening aims to identify cancers in early stages when prognosis is better and treatments less invasive. We describe inter- and intra-provincial variation in the percentage of screen-detected cases under publicly funded healthcare systems and factors related to having screen- vs non-screen-detected breast cancer across five Canadian provinces. METHODS: Women aged 40+ diagnosed with incident breast cancer from 2007 to 2012 in five Canadian provinces were identified from their respective provincial cancer registries. Standardized provincial datasets were created linking screening, health administrative, and claims data. Province-specific logistic regression models were used to evaluate the association of demographic and healthcare utilization factors in each province with the odds of screen-detected cancer. RESULTS: There was significant inter- and intra-provincial variation by age. Screen detection ranged from 42% to 52% in ages 50-69 but women aged 50-59 had approximately 4-8% lower screen detection than those aged 60-69 in all provinces. Screening associations with income quintile and rurality varied across provinces. Those least likely to be screen-detected within a province were consistently in the lowest income quintile; OR ranged from 0.62-0.89 relative to highest income quintile/urban patients aged 50-69. Lack of visits to primary care 30 months prior to diagnosis was also consistently associated with lower odds of screen detection (OR range, 0.37-0.76). CONCLUSION: Breast cancer screen detection rates in the Canadian provinces examined are relatively high. Associations with income-rurality indicate a need for greater attention and/or targeted outreach to specific communities and/or provincial regions to improve access to breast cancer screening services intra-provincially.

Importance of quality in breast cancer screening practice - a natural experiment in Alberta, Canada.

OBJECTIVES: Regular breast cancer screening is a widely used cancer prevention strategy. Important quality indicators of screening include cancer detection rate, false positive rate, benign biopsy rate and post-screen invasive cancer rate. We compared quality indicators of community radiology clinics to those of 'Screen Test', which feature centralised batch reading and quality control processes. Both types of providers operated under a single provincial Breast Cancer Screening Programme. SETTING: Community radiology clinics are operated by independent fee-for-service radiologists serving large and small communities throughout the Canadian province of Alberta. Launched by the provincial cancer agency, the Screen Test operates two physical clinics serving metropolises and mobile units serving remote regions. Eligible women may self-refer to any provider for screening mammography. PARTICIPANTS: Women aged 50 to 69 years who had at least one screening mammogram between July 2006 and June 2010 in Alberta were included. Women with missing health region information or prior breast cancer diagnosis were excluded. RESULTS: A total of 389 788 screening mammograms were analysed, of which 12.7% were performed by Screen Test. Compared with Screen Test during 2006 to 2008, community radiology clinics had a lower cancer detection rate (3.6 vs 4.6 per 1000 screens, risk ratio (RR): 0.81, 95% CI: 0.67 to 0.98) and a much higher false positive rate (9.4% vs 3.4%, RR: 2.72, 95% CI: 2.55 to 2.90). Most other performance indicators were also better in Screen Test overall and across all health regions. These performance indicators were similar during 2008 to 2010, showing no improvement with time. CONCLUSIONS: Screen Test has a quality assurance process in place and performed significantly better. This provides empirical evidence of the effectiveness of a quality assurance process and may explain some of the large differences in breast cancer screening indicators between provinces and countries with formal programmes and those without.

Effectiveness of a Lay Navigation Program in an Academic Cancer Center.

PURPOSE: A navigation program with lay navigators that targets patients with cancer who are receiving multiple treatment modalities was launched with the goal of improving care coordination. PATIENTS AND METHODS: Pseudo-randomization and mixed methods were used to evaluate the program: patients with even-numbered medical records were assigned to navigation help, and patients with odd-numbered medical records made up the control group. Eligible patients were those scheduled to receive at least two treatment modalities. Intent-to-treat, as-treated, and high-user cohorts with propensity matched controls were used to assess the outcomes: patient experience, emergency room (ER) use, and unplanned hospitalizations. In-depth patient interviews explored how and why patients interacted with the navigator program and overall patient experience. RESULTS: Marginally lower incidence rate ratios (IRRs) for both ER visits (IRR, 1.17; 95% CI, 1.00 to 1.36) and unplanned hospitalizations (IRR, 1.18; 95% CI, 0.97 to 1.43) occurred in as-treated patients who used navigation help and who lived within 50 miles of Stanford Hospital compared with their matched controls; other cohort analyses had similar results. Survey scores for patients who received help with navigation did not differ significantly from those for corresponding controls in any of the analytic cohorts. Patient interviews suggested that the navigation program had low visibility among patients and that lay navigators drove use of the program. Patient-reported positive experiences included getting help with complex scheduling, alleviating anxiousness through access to information and educational resources, and getting help with activities outside traditional health care; negative experiences stemmed from having expectations that were not met. CONCLUSION: Marginally lower rates of ER visits and unplanned hospitalizations for a small subset of patients, low penetration of the navigation program, and mixed comments from patient interviews suggest that a navigation program with a broad scope that targets a large population is not effective. Modifying the program to have a narrower scope of practice may help better target anxious or high-risk patients.

Negotiating Lay and Clinical Issues: Implementing a Lay Navigation Program in Cancer Care.

PURPOSE: Patients with cancer face daunting coordination problems at a vulnerable time. Lay navigation programs offer 1 approach to address these problems, but how to best implement these programs presents challenges. We sought to describe those implementation challenges at 1 academic cancer center to inform future efforts. METHODS: We performed a mixed methods study using standard implementation outcomes 1 year after program initiation. Quantitative data from the electronic medical record and qualitative data from in-depth interviews, focus groups, and ethnographic observations were included in analyses. The study took place at a National Cancer Institute-designated comprehensive cancer center across 12 tumor-specific clinics. RESULTS: Supportive care concerns, scheduling, and clinical-related issues were the most frequent issues navigators encountered. Effective navigation required continuous, time-consuming, invisible work, including building and maintaining a broad knowledge base of resources and health system processes, as well as cultivating relationships with diverse and changing clinical teams. The acceptability and appropriateness of lay navigator activities were mixed among clinic and social work staff, related to negotiating lines between clinical and nonclinical care. CONCLUSION: After 1 year of implementation, lay navigators still found it difficult to interpret and prioritize complex patient needs in a way that all clinical staff found appropriate. Negotiating these issues has made it difficult to develop the strong relationships with clinical teams that are needed for an integrated approach to patient care. To successfully coordinate patient care, it seems that lay navigation programs should be integrated with clinical teams to provide more seamless patient care.

Beyond satisfaction scores: exploring emotionally adverse patient experiences.

OBJECTIVES: Although improving the average patient experience is at the center of recent efforts to make cancer care more patient centered, extreme experiences may be more informative for quality improvement. Little is known about the most deeply dissatisfying experiences that predispose disengagement and negatively influence patient outcomes. We sought to establish a framework for emotionally adverse patient experiences and identify the range of common causes. STUDY DESIGN: Qualitative study including in-depth interviews and free-text survey comments. METHODS: Thematic analysis of 20 open-ended patient interviews and 2389 free-text survey comments collected in a medical center's cancer clinics. RESULTS: Emotionally adverse experiences were rarely reported in survey comments (96; 4.0%) but more frequently discussed in interviews (12 interview participants). Such experiences were identified through explicit statements of negative emotion, language, syntax, and tone. Among these rare comments, hostility as an indicator was easiest to identify, whereas passive expressions of fear or hopelessness were less reliably identified. We identified 3 mutually inclusive high-level domains of triggers of negative emotion-system issues, technical processes, and interpersonal processes-and 10 themes within those domains. There was wide variation in the causes of emotionally adverse experiences and evidence of a complex interplay of patient expectations and preconditions that influenced the perception of negative experiences. CONCLUSIONS: This study presents a taxonomy for classifying emotionally adverse patient experiences expressed in free-text format. Further research should test how perceptions of adverse experiences correspond to recorded ratings of patient satisfaction and subsequent enrollment or utilization.

Development of a tailored survey to evaluate a patient-centered initiative.

OBJECTIVES: Patient-centered care initiatives have proliferated, but assessing their effectiveness requires measures tailored to their likely effects. In this article, we describe the development and pilot testing of patient surveys used to assess change in patients' cancer care experiences over time in response to a patient-centered care initiative. STUDY DESIGN: Prospective case series. METHODS: Domains of patient-centered care were informed by the goals of the initiative and a review of existing tools. Items were selected and modified from 6 domains of validated or semivalidated instruments. Items were piloted with patients with cancer in waiting room settings to further assess the relevance and clarity of items, whether important concepts were missing, and acceptability regarding place and timing of the surveys and to estimate baseline top box scores (percentage of patients scoring an item the highest quality level) to minimize likely ceiling effects. The instrument was then administered to a consecutive sample of Stanford Cancer Center patients. Baseline item responses, Cronbach's alpha, and response bias were estimated. RESULTS: Items were modified based on patient feedback, top box scores, and reassessment of the domains. Over 6 months, 11,273 patients were surveyed, with a 49.7% response rate. Baseline top box scores ranged from 41.7% to 75.0% for any given item. Reliability and internal consistency were high for all domains (Cronbach's alpha ≥0.80) except for the access domain. CONCLUSIONS: We developed reliable instruments to evaluate the essential elements of a patient-centered care initiative at an academic medical center, which minimized patient burden and maximized the response rate.

Re-excision and survival following breast conserving surgery in early stage breast cancer patients: a population-based study.

BACKGROUND: Increasing population-based evidence suggests that patients who receive breast conserving surgery (BCS) plus radiotherapy have superior survival than those who receive mastectomy. It is unclear, however, how BCS followed by re-excision is associated with all-cause and breast cancer-specific mortality, and whether the BCS survival advantage is maintained if re-excision is needed. The aim of this study was to investigate the clinical, patient, provider and geographic variation associated with receipt of re-excision surgery, and to examine the relationship between re-excision and all-cause and breast cancer-specific mortality. METHODS: All women diagnosed with stage I-III breast cancer in Alberta, Canada from 2002 to 2009 were identified from the Alberta Cancer Registry, of which 11,626 were eligible for study inclusion. Type of first breast cancer surgery after diagnosis, subsequent re-excisions within 1 year, surgeon (anonymized), and hospital were obtained from provincial physician claims data. Multilevel logistic regression with surgeons and hospitals as crossed random effects was used to estimate the adjusted odds ratios of re-excision by the factors of interest. Poisson regression models were fitted to compare all-cause and breast cancer-specific mortality by surgical pattern. RESULTS: Re-excision surgery was received by 19% (N = 5659) of patients who initially received BCS. The adjusted odds of re-excision varied significantly by geography of surgery, and by individual surgeon among stage I and II patients beyond the variation explained by the factors investigated (Stage I OR standard deviation (SD) = 0.43; stage II OR SD = 0.39). Patients who were treated with BCS plus re-excision surgery with either mastectomy or further BCS had similar all-cause and breast cancer-specific mortality as those treated with BCS without re-excision. CONCLUSION: These results suggest that breast cancer patients who are treated with BCS plus re-excision surgery by either mastectomy or further BCS have similar survival as those treated with BCS without re-excision. The significant variation in the likelihood of re-excision by geography and by individual surgeon is concerning, especially given the costs to the patient associated with additional surgery and the financial costs to the health system.

The impact of false positive breast cancer screening mammograms on screening retention: A retrospective population cohort study in Alberta, Canada.

OBJECTIVES: The impact of false positives on breast cancer screening retention is inconsistent across international studies. We investigate factors associated with screening retention, including false positive screening results, invasiveness of diagnostic procedures, and geographic variation in Alberta, Canada. METHODS: A total of 213 867 women aged 50-67 years who had an index screen mammogram between July 2006 and June 2008 were evaluated at 30 months post index screen to determine the screening retention rate. The association of screening retention with invasiveness of the diagnostic procedure, time to diagnostic resolution, and region of residence were investigated using multivariable log binomial regression, adjusting for women's age. RESULTS: Women with false positive screening results were less likely to return for their next recommended screening than those with a true negative result (62.0% vs. 68.7%). Compared to women with normal screening results, the adjusted risk ratios of fail-to-rescreen for women with imaging-only follow-up, needle sampling, and open biopsy were 1.08 (95% CI: 1.05-1.12), 1.72 (95% CI: 1.44-2.07) and 2.29 (95% CI: 2.09-2.50) respectively. Screening retention rates were slightly higher for rural residents than urban residents. Time to diagnostic resolution was not associated with screening retention. Screening retention peaked at one year from the index date of the previous screening. CONCLUSION: Higher awareness of the strong negative impact that biopsies in the case of a false positive screening have on screening retention is needed. Such awareness can inform intervention strategies to mitigate the impact and improve screening retention rate.

Lessons Learned: It Takes a Village to Understand Inter-Sectoral Care Using Administrative Data across Jurisdictions.

Cancer care is complex and exists within the broader healthcare system. The CanIMPACT team sought to enhance primary cancer care capacity and improve integration between primary and cancer specialist care, focusing on breast cancer. In Canada, all medically-necessary healthcare is publicly funded but overseen at the provincial/territorial level. The CanIMPACT Administrative Health Data Group's (AHDG) role was to describe inter-sectoral care across five Canadian provinces: British Columbia, Alberta, Manitoba, Ontario and Nova Scotia. This paper describes the process used and challenges faced in creating four parallel administrative health datasets. We present the content of those datasets and population characteristics. We provide guidance for future research based on 'lessons learned'. The AHDG conducted population-based comparisons of care for breast cancer patients diagnosed from 2007-2011. We created parallel provincial datasets using knowledge from data inventories, our previous work, and ongoing bi-weekly conference calls. Common dataset creation plans (DCPs) ensured data comparability and documentation of data differences. In general, the process had to be flexible and iterative as our understanding of the data and needs of the broader team evolved. Inter-sectoral data inconsistencies that we had to address occurred due to differences in: 1) healthcare systems, 2) data sources, 3) data elements and 4) variable definitions. Our parallel provincial datasets describe the breast cancer diagnostic, treatment and survivorship phases and address ten research objectives. Breast cancer patient demographics reflect inter-provincial general population differences. Across provinces, disease characteristics are similar but underlying health status and use of healthcare services differ. Describing healthcare across Canadian jurisdictions assesses whether our provincial healthcare systems are delivering similar high quality, timely, accessible care to all of our citizens. We have provided a description of our experience in trying to achieve this goal and, for future use, we include a list of 'lessons learned' and a list of recommended steps for conducting this kind of work. KEY FINDINGS: The conduct of inter-sectoral research using linked administrative health data requires a committed team that is adequately resourced and has a set of clear, feasible objectives at the start.Guiding principles include: maximization of sectoral participation by including single-jurisdiction expertise and making the most inclusive data decisions; use of living documents that track all data decisions and careful consideration about data quality and availability differences.Inter-sectoral research requires a good understanding of the local healthcare system and other contextual issues for appropriate interpretation of observed differences.

Improving Care With a Portfolio of Physician-Led Cancer Quality Measures at an Academic Center.

PURPOSE: Development and implementation of robust reporting processes to systematically provide quality data to care teams in a timely manner is challenging. National cancer quality measures are useful, but the manual data collection required is resource intensive, and reporting is delayed. We designed a largely automated measurement system with our multidisciplinary cancer care programs (CCPs) to identify, measure, and improve quality metrics that were meaningful to the care teams and their patients. METHODS: Each CCP physician leader collaborated with the cancer quality team to identify metrics, abiding by established guiding principles. Financial incentive was provided to the CCPs if performance at the end of the study period met predetermined targets. Reports were developed and provided to the CCP physician leaders on a monthly or quarterly basis, for dissemination to their CCP teams. RESULTS: A total of 15 distinct quality measures were collected in depth for the first time at this cancer center. Metrics spanned the patient care continuum, from diagnosis through end of life or survivorship care. All metrics improved over the study period, met their targets, and earned a financial incentive for their CCP. CONCLUSION: Our quality program had three essential elements that led to its success: (1) engaging physicians in choosing the quality measures and prespecifying goals, (2) using automated extraction methods for rapid and timely feedback on improvement and progress toward achieving goals, and (3) offering a financial team-based incentive if prespecified goals were met.

Patient Perception of Speech Outcomes: The Relationship Between Clinical Measures and Self-Perception of Speech Function Following Surgical Treatment for Oral Cancer.

PURPOSE: Treatment for oral cancer can result in speech impairments that can have varying impacts on patient quality of life. This study explored the relationship between clinical measures of speech impairment and the perception that patients had of this change in the early stage of recovery. METHOD: This was a quasi-experimental 1-group pre-post study design carried out on 10 patients with surgical intervention for oral cancer. Two clinical measures (word intelligibility and consonant phoneme error) and 2 patient-perception measures (Speech Handicap Index total score and Speech Handicap Index patient criteria score) were collected at preoperative and 1-month postoperative appointments. RESULTS: Qualitative analysis revealed discordance between clinical and patient-perceived measures in 4 of 10 patients. Change in consonant phoneme error and change in word intelligibility were significantly correlated (r = .827). Furthermore, on average, statistically significant relationships were not found between clinical and patient-perceived measures or between the 2 patient-perception measures. CONCLUSIONS: Discordance between clinical and patient-perceived measures was observed in almost half of the sample, indicating that clinical tests did not fully explain the extent of impairment perceived by patients. Speech outcomes should focus on both types of measures, and patient perception outcomes should be carefully considered when recommending speech therapy.

Factors associated with mode of colorectal cancer detection and time to diagnosis: a population level study.

BACKGROUND: Although it is well-known that early detection of colorectal cancer (CRC) is important for optimal patient survival, the relationship of patient and health system factors with delayed diagnosis are unclear. The purpose of this study was to identify the demographic, clinical and healthcare factors related to mode of CRC detection and length of the diagnostic interval. METHODS: All residents of Alberta, Canada diagnosed with first-ever incident CRC in years 2004-2010 were identified from the Alberta Cancer Registry. Population-based administrative health datasets, including hospital discharge abstract, ambulatory care classification system and physician billing data, were used to identify healthcare services related to CRC diagnosis. The time to diagnosis was defined as the time from the first CRC-related healthcare visit to the date of CRC diagnosis. Mode of CRC detection was classified into three groups: urgent, screen-detected and symptomatic. Quantile regression was performed to assess factors associated with time to diagnosis. RESULTS: 9626 patients were included in the study; 25% of patients presented as urgent, 32% were screen-detected and 43% were symptomatic. The median time to diagnosis for urgent, screen-detected and symptomatic patients were 6 days (interquartile range (IQR) 2-14 days), 74 days (IQR 36-183 days), 84 days (IQR 39-223 days), respectively. Time to diagnosis was greater than 6 months for 27% of non-urgent patients. Healthcare factors had the largest impact on time to diagnosis: 3 or more visits to a GP increased the median by 140 days whereas 2 or more visits to a GI-specialist increased it by 108 days compared to 0-1 visits to a GP or GI-specialist, respectively. CONCLUSION: A large proportion of CRC patients required urgent work-up or had to wait more than 6 months for diagnosis. Actions are needed to reduce the frequency of urgent presentation as well as improve the timeliness of diagnosis. Findings suggest a need to improve coordination of care across multiple providers.

Primary care physician use across the breast cancer care continuum: CanIMPACT study using Canadian administrative data.

OBJECTIVE: To describe primary care physician (PCP) use and continuity of PCP care across the breast cancer care continuum. DESIGN: Population-based, retrospective cohort study using provincial cancer registries linked to health administrative databases. SETTING: British Columbia, Manitoba, and Ontario. PARTICIPANTS: All women with incident invasive breast cancer from 2007 to 2012 in Manitoba and Ontario and from 2007 to 2011 in British Columbia. MAIN OUTCOME MEASURES: The number and proportions of visits to PCPs were determined. Continuity of care was measured using the Usual Provider of Care index calculated as the proportion of visits to the most-often-visited PCP in the 6 to 30 months before a breast cancer diagnosis (baseline) and from 1 to 3 years following a breast cancer diagnosis (survivorship). RESULTS: More than three-quarters of patients visited their PCPs 2 or more times during the breast cancer diagnostic period, and more than 80% of patients had at least 1 PCP visit during breast cancer adjuvant treatment. Contact with the PCP decreased over time during breast cancer survivorship. Of the 3 phases, women appeared to be most likely to not have PCP contact during adjuvant treatment, with 10.7% (Ontario) to 18.7% (British Columbia) of women having no PCP visits during this phase. However, a sizable minority of women had at least monthly visits during the treatment phase, particularly in Manitoba and Ontario, where approximately a quarter of women saw a PCP at least monthly. We observed higher continuity of care with PCPs in survivorship (compared with baseline) in all provinces. CONCLUSION: Primary care physicians were generally involved throughout the breast cancer care continuum, but the level of involvement varied across care phases and by province. Future interventions will aim to further integrate primary and oncology care.