Developing innovative models of care for cancer survivors: use of implementation science to guide evaluation of appropriateness and feasibility.

PURPOSE: Limited understanding of factors affecting uptake and outcomes of different cancer survivorship care models hampers implementation of best practices. We conducted a formative evaluation of stakeholder-perceived acceptability and feasibility of an embedded primary care provider (PCP) survivorship care model. METHODS: We identified clinical, operational, and patient stakeholders within Kaiser Permanente Southern California and conducted semi-structured interviews. Analyses were guided by the Consolidated Framework for Implementation Research (CFIR), an integrated framework from the field of implementation science. Deductive thematic categories were derived a priori from CFIR domains; thematic sub-categories were developed inductively. RESULTS: We interviewed 12 stakeholders; multiple themes were identified. Acceptability: oncologists and operational leaders perceived that the model was an acceptable solution to issues of capacity and efficiency with the potential to improve quality; however, several oncologists perceived negative consequences including "[loss of] the joy of medicine." Patients were less enthusiastic, fearing the introduction of "[someone] who doesn't know me." Feasibility: confidence was high that this model can succeed, although there was concern about finding the right PCP and investment in training and staff support. Culture/climate: numerous system-level facilitators were identified, including encouragement of innovation and familiarity with developing new models. CONCLUSIONS: Formative evaluation is a critical pre-implementation process. Acceptability and feasibility for this model were high among oncologists and operational leaders but patients were ambivalent. Keys to successful implementation include training and support of engaged PCPs and a patient transition plan introduced early in the care trajectory.

Survivorship care plans: are randomized controlled trials assessing outcomes that are relevant to stakeholders?

PURPOSE: The purpose of this study was to compare outcomes assessed in extant randomized controlled trials (RCTs) to outcomes that stakeholders expect from survivorship care plans (SCPs). To facilitate the transition from active treatment to follow-up care for the 15.5 million US cancer survivors, many organizations require SCP use. However, results of several RCTs of SCPs' effectiveness have been null, possibly because they have evaluated outcomes on which SCPs should be expected to have limited influence. Stakeholders (e.g., survivors, oncologists) may expect outcomes that differ from RCTs' outcomes. METHODS: We identified RCTs' outcomes using a PubMed literature review. We identified outcomes that stakeholders expect from SCPs using semistructured interviews with stakeholders in three healthcare systems in the USA and Canada. Finally, we mapped RCTs' outcomes onto stakeholder-identified outcomes. RESULTS: RCT outcomes did not fully address outcomes that stakeholders expected from SCPs, and RCTs assessed outcomes that stakeholders did not expect from SCPs. RCTs often assessed outcomes only from survivors' perspectives. CONCLUSIONS: RCTs of SCPs' effectiveness have not assessed outcomes that stakeholders expect. To better understand SCPs' effectiveness, future RCTs should assess outcomes of SCP use that are relevant from the perspective of multiple stakeholders. IMPLICATIONS FOR CANCER SURVIVORS: SCPs' effectiveness may be optimized when used with an eye toward outcomes that stakeholders expect from SCPs. For survivors, this means using SCPs as a map to guide them with respect to what kind of follow-up care they should seek, when they should seek it, and from whom they should seek it.

Low-value care for acute sinusitis encounters: who's choosing wisely?

OBJECTIVES: To assess acute sinusitis (AS) encounters in primary care (PC), urgent care (UC), and emergency department (ED) settings for adherence to recommendations to avoid low-value care. STUDY DESIGN: A retrospective, observational study of adult AS encounters (2010-2012) within a large integrated healthcare system. METHODS: We compared ED and UC encounters with PC visits, adjusting for differences in patient characteristics. PRIMARY OUTCOMES: adherence to recommendations to avoid antibiotics and a computed tomography (CT) scan of the face, head, or sinuses. SECONDARY OUTCOMES: length of symptoms and adherence with AS recommendations. RESULTS: Of 152,774 AS encounters, 89.2% resulted in antibiotics and 1.1% resulted in a CT scan. Compared with PC encounters, ED encounters were less likely to result in antibiotics (adjusted odds ratio [AOR], 0.57; 95% CI, 0.50-0.65) but more likely to result in a CT scan (AOR, 59.4; 95% CI, 51.3-68.7), while UC encounters were more likely to result in both antibiotics (AOR, 1.12; 95% CI, 1.08-1.17) and CT imaging (AOR, 2.4; 95% CI, 2.1-2.7). Chart review of encounters resulting in antibiotics found that 50% were inappropriately prescribed for symptoms of ≤7 days' duration (95% CI, 41%-58%), while 35% were appropriately prescribed for symptoms of ≥14 days' duration (95% CI, 27%-44%). Only 29% (95% CI, 22%-36%) of encounters were consistent with guideline-adherent care. CONCLUSIONS: AS encounters in an integrated health system infrequently result in CT imaging, but antibiotic treatment is common. Differences exist across acute care settings, but improved antibiotic stewardship is needed in all settings.

Use of imaging for staging of early-stage breast cancer in two integrated health care systems: adherence with a choosing wisely recommendation.

PURPOSE: Advanced imaging is commonly used for staging of early-stage breast cancer, despite recommendations against this practice. The objective of this study was to evaluate and compare use of imaging for staging of breast cancer in two integrated health care systems, Kaiser Permanente (KP) and Intermountain Healthcare (IH). We also sought to distinguish whether imaging was routine or used for diagnostic purposes. METHODS: We identified patients with stages 0 to IIB breast cancer diagnosed between 2010 and 2012. Using KP and IH electronic health records, we identified use of computed tomography, positron emission tomography, or bone scintigraphy 30 days before diagnosis to 30 days postsurgery. We performed chart abstraction on a random sample of patients who received a presurgical imaging test to identify indication. RESULTS: For the sample of 10,010 patients, mean age at diagnosis was 60 years (range, 22 to 99 years); with 21% stage 0, 47% stage I, and 32% stage II. Overall, 15% of patients (n = 1,480) received at least one imaging test during the staging window, 15% at KP and 14% at IH (P = .5). Eight percent of patients received imaging before surgery, and 7% postsurgery. We found significant intraregional variation in imaging use. Chart abstraction (n = 129, 16% of patients who received presurgical imaging) revealed that 48% of presurgical imaging was diagnostic. CONCLUSION: Use of imaging for staging of low-risk breast cancer was similar in both systems, and slightly lower than has been reported in the literature. Approximately half of imaging tests were ordered in response to a sign or symptom.

Navigating the urban food environment: challenges and resilience of community-dwelling older adults.

OBJECTIVE: Identify factors involved in food shopping among older urban adults. DESIGN: A qualitative study of 30 in-depth interviews and 15 "tagalong" shopping trip observations were conducted. SETTING: Brooklyn, New York. PARTICIPANTS: Black, white, and Latino men and women aged 60-88 years. MAIN OUTCOME MEASURE: Transcripts were coded inductively to identify emergent themes. RESULTS: Older adults shopped at multiple stores to obtain the quality of foods preferred at prices that fit their food budgets. Participants often traveled outside their neighborhoods to accomplish this, and expressed dissatisfaction with the foods locally available. Adaptive food shopping behaviors included walking or the use of public transit to purchase food in small batches, as well as reliance on community resources and social network members. CONCLUSIONS AND IMPLICATIONS: Participants identified a number of multilayered factors and challenges involved in procuring food. These factors conform to elements of ecological behavioral models described as intrapersonal, social, and environmental level influences and have resulted in adaptive behaviors for this population. These findings provide evidence that can be used to develop more effective programs, as well as promote testable interventions aimed at keeping older adults independent and capable of acquiring food that meets their age-specific needs.

Correlates of drug treatment program staff's self efficacy to support their clients' hepatitis C virus (HCV) related needs.

Drug treatment staff are uniquely situated to support their clients' HCV related needs, and those with greater self efficacy to do so are more likely to provide this support. Using data collected from staff (N = 140) in 6 drug treatment programs in New York City, we determined the correlates of this self efficacy. Results indicate that medically credentialed staff and staff with more hepatitis C knowledge have greater self efficacy to support their clients' HCV related needs. There was no relationship between this self efficacy and the staff member's own HCV infection or that of a close relative. Efforts should focus on increasing staff's HCV knowledge in order to increase their confidence in providing HCV related support to their clients.

Drug treatment program patients' hepatitis C virus (HCV) education needs and their use of available HCV education services.

BACKGROUND: In spite of the disproportionate prevalence of hepatitis C virus (HCV) infection among drug users, many remain uninformed or misinformed about the virus. Drug treatment programs are important sites of opportunity for providing HCV education to their patients, and many programs do, in fact, offer this education in a variety of formats. Little is known, however, about the level of HCV knowledge among drug treatment program patients, and the extent to which they utilize their programs' HCV education services. METHODS: Using data collected from patients (N = 280) in 14 U.S. drug treatment programs, we compared patients who reported that they never injected drugs (NIDUs) with past or current drug injectors (IDUs) concerning their knowledge about HCV, whether they used HCV education opportunities at their programs, and the facilitators and barriers to doing so. All of the programs were participating in a research project that was developing, implementing, and evaluating a staff training to provide HCV support to patients. RESULTS: Although IDUs scored higher on an HCV knowledge assessment than NIDUs, there were many gaps in HCV knowledge among both groups of patients. To address these knowledge gaps, all of the programs offered at least one form of HCV education: all offered 1:1 sessions with staff, 12 of the programs offered HCV education in a group format, and 11 of the programs offered this education through pamphlets/books. Only 60% of all of the participating patients used any of their programs' HCV education services, but those who did avail themselves of these HCV education opportunities generally assessed them positively. In all, many patients were unaware that HCV education was offered at their programs through individual sessions with staff, group meetings, and books/pamphlets, (42%, 49%, and 46% of the patients, respectively), and 22% were unaware that any HCV education opportunities existed. CONCLUSION: Efforts especially need to focus on ensuring that all drug treatment program patients are made aware of and encouraged to use HCV education services at their programs.