The exercise in all chemotherapy trial.

BACKGROUND: Multiple international organizations have called for exercise to become standard practice in the setting of oncology care. The feasibility of integrating exercise within systemic chemotherapy has not been investigated. METHODS: Patients slated to receive infusion therapy between April 2017 and October 2018 were screened for possible inclusion. The study goal was to establish the acceptability and feasibility of embedding an exercise professional into the chemotherapy infusion suite as a method of making exercise a standard part of cancer care. The exercise prescriptions provided to patients were individualized according to results of brief baseline functional testing. RESULTS: In all, 544 patients were screened, and their respective treating oncologists deemed 83% of them to be medically eligible to participate. After further eligibility screening, 226 patients were approached. Nearly 71% of these patients (n = 160) accepted the invitation to participate in the Exercise in All Chemotherapy trial. Feasibility was established because 71%, 55%, 69%, and 63% of the aerobic, resistance, balance, and flexibility exercises prescribed to patients were completed. Qualitative data also supported the acceptability and feasibility of the intervention from the perspective of patients and clinicians. The per-patient cost of the intervention was $190.68 to $382.40. CONCLUSIONS: Embedding an exercise professional into the chemotherapy infusion suite is an acceptable and feasible approach to making exercise standard practice. Moreover, the cost of the intervention is lower than the cost of other common community programs. Future studies should test whether colocating an exercise professional with infusion therapy could reach more patients in comparison with not colocating. LAY SUMMARY: Few studies have tested the implementation of exercise for patients with cancer by embedding an exercise professional directly into the chemotherapy infusion suite. The Exercise in All Chemotherapy trial shows that this approach is both acceptable and feasible from the perspective of clinicians and patients.

Reporting provider performance: what can be learned from the experience of multi-stakeholder community coalitions?

OBJECTIVES: This analysis assessed the evolution of public reporting of provider performance in Aligning Forces for Quality (AF4Q) alliances, contrasted alliances that stopped reporting with those that plan to continue, and drew insights from alliance public reporting efforts for the national transparency movement. METHODS: Combined with document review, qualitative research methods were used to analyze interview data collected, over a nearly 10-year period, from the 16 participating alliances. RESULTS: AF4Q alliances made their greatest contributions to provider transparency in reporting ambulatory quality and patient experience measures. However, reporting ambulatory cost/efficiency/utilization measures was more challenging for alliances. Alliances contributed the least with respect to measures of inpatient performance. Six alliances ceased reporting at the end of the AF4Q program because of their inability to develop stable funding sources and overcome stakeholder skepticism about the value of public reporting. Insights provided by alliance leaders included the need to: focus on provider, rather than consumer, responses to public reports as the most likely avenue for improving quality; address the challenge of funding the reporting infrastructure from the beginning; explore collaborations with other entities to increase public reporting efficiency; and develop a strategy for responding to efforts at the national level to increase the availability of information on provider performance. CONCLUSION: The AF4Q initiative demonstrated that a wide variety of voluntary stakeholder coalitions could develop public reports with financial and technical support. However, the contents of these reports varied considerably, reflecting differences in local environments and alliance strategies. The challenges faced by alliances to maintain their reporting efforts were substantial, and not all alliances chose to report. Nevertheless, there are potential roles for alliances going forward in contributing to the national transparency movement.

The Aligning Forces for Quality initiative: background and evolution from 2005 to 2015.

OBJECTIVE: The Robert Wood Johnson Foundation's (RWJF's) Aligning Forces for Quality (AF4Q) program was the largest privately funded, community-based quality improvement initiative to date, providing funds and technical assistance (TA) to 16 multi-stakeholder alliances located throughout the United States. This article describes the AF4Q initiative's underlying theory of change, its evolution over time, and the key activities undertaken by alliances. STUDY DESIGN: Descriptive overview of a multi-site, community-based quality improvement initiative. METHODS: We summarized information from program documents, program meetings, observation of alliance activities, and interviews with RWJF staff, TA providers, and AF4Q alliance stakeholders. RESULTS: The AF4Q program was a dynamic initiative, expanding and evolving over time. The underlying theory of change was based on the notion that an aligned, multi-stakeholder approach is superior to independent siloed efforts by stakeholders. Participating alliances developed or strengthened programming to varying degrees in 5 main programmatic areas: (1) measurement and public reporting of healthcare quality, patient experience, cost, and efficiency for ambulatory physician practices and hospitals; (2) efforts to engage consumers in health, healthcare, and alliance governance (consumer engagement); (3) adoption and spread of effective strategies to improve care delivery; (4) advancing healthcare equity; and (5) integration of alliance activities with payment reform initiatives. CONCLUSION: The AF4Q initiative was an ambitious program affecting multiple leverage points in the healthcare system. AF4Q alliances were provided a similar set of expectations, and given financial support and access to substantial TA. There was considerable variation in how alliances addressed the AF4Q programmatic areas, given differences in their composition, market structure, and history.

Producing public reports of physician quality at the community level: the Aligning Forces for Quality initiative experience.

OBJECTIVES: To describe the approaches used by the Aligning Forces for Quality (AF4Q) alliances in producing community-based reports of physician quality and to assess the contribution of these reports to existing physician performance information. STUDY DESIGN: The study included semi-structured interviews with alliance stakeholders and tracking of the number and content of physician performance reports in 14 AF4Q initiative communities and 7 comparison communities. METHODS: The study used qualitative analysis of interview data and systematic tracking of the number and content of physician performance reports over time. RESULTS: Report production occurred in several stages including initiation, measure selection/specification, measure construction, and dissemination. The measure selection/specification process was often the first major act undertaken by alliances under the AF4Q initiative grant. Alliances utilized nationally endorsed performance measures and made a strategic decision to gain buy-in with physicians. Alliances have experienced greater difficulty in producing buy-in for patient experience measures. The primary decision point for measure construction was the use of administrative claims data or physician-provided medical records data. Overall, AF4Q alliances have contributed to an increase in physician performance information in their communities. CONCLUSIONS: Our findings suggest that the AF4Q initiative has accelerated the development and content of physician performance measures in AF4Q communities.

Using websites to engage consumers in managing their health and healthcare.

OBJECTIVE: This study provides insight into the potential of local community health information websites to cultivate and support consumer engagement through website positioning and content choices. STUDY DESIGN: This descriptive study compared health-related websites maintained by 16 multi-stakeholder community alliances charged with improving consumer engagement and public reporting of provider performance data. METHODS: We systematically assessed website messaging, content, and the presence of explicit connections among information and tools related to consumer engagement behaviors for 32 websites maintained by alliances as of November 2011. These findings were triangulated with information about alliances' public reporting activities from key informant interviews (2007-2011) with stakeholders in 14 alliances. RESULTS: A total of 25 of the 32 alliance websites contained information for consumers, and 14 of those included information related to at least 3 of 4 consumer engagement behaviors: shopping for high-quality providers or treatments, self-advocacy in healthcare encounters, self-management of illness, and partaking in general healthy behaviors. Positioning strategies and tactics to attract consumers varied widely across alliances. Some targeted specific conditions or behaviors; others took a broader community approach. Two alliances had strong alignment between website messaging and consumer engagement content, 7 had moderate alignment, and 7 had limited alignment. CONCLUSIONS: Although alliances have been experimenting with a wide array of website approaches, their promise as a tool to improve consumer engagement is still uncertain. Further research that addresses the comparative value of different website approaches is needed.