Health-care organization characteristics in cancer care delivery: an integrated conceptual framework with content validation.

Context can influence cancer-related outcomes. For example, health-care organization characteristics, including ownership, leadership, and culture, can affect care access, communication, and patient outcomes. Health-care organization characteristics and other contextual factors can also influence whether and how clinical discoveries reduce cancer incidence, morbidity, and mortality. Importantly, policy, market, and technology changes are transforming health-care organization design, culture, and operations across the cancer continuum. Consequently, research is essential to examine when, for whom, and how organizational characteristics influence person-level, organization-level, and population-level cancer outcomes. Understanding organizational characteristics-the structures, processes, and other features of entities involved in health care delivery-and their dynamics is an important yet understudied area of care delivery research across the cancer continuum. Research incorporating organizational characteristics is critical to address health inequities, test care delivery models, adapt interventions, and strengthen implementation. The field lacks conceptual grounding, however, to help researchers identify germane organizational characteristics. We propose a framework identifying organizational characteristics relevant for cancer care delivery research based on conceptual work in health services, organizational behavior, and management science and refined using a systematic review and key informant input. The proposed framework is a tool for organizing existing research and enhancing future cancer care delivery research. Following a 2012 Journal of the National Cancer Institute monograph, this work complements National Cancer Institute efforts to stimulate research addressing the relationship between cancer outcomes and contextual factors at the patient, provider, team, delivery organization, community, and health policy levels.

Team complexity and care coordination for cancer survivors with multiple chronic conditions: a mixed methods study.

PURPOSE: Little is known about the perceptions and experiences of care received from healthcare teams among cancer survivors with multiple chronic conditions (MCCs). METHODS: Cancer survivors completed an online survey (N=441) of which 12 participated in an interview. Team complexity was operationalized based on team size, clinician specialties, and health system affiliation. Kilpatrick's Patient-Perceptions of Team Effectiveness (PTE) questionnaire measured team effectiveness. Constant comparative method was used to identify care coordination challenges and facilitators from interviews. RESULTS: Mean age at cancer diagnosis was 45 years (SD=14), 68% were 5 years from diagnosis, the most common cancer was breast (27%), and two-thirds had two or more pre-diagnosis comorbidities. Sixty percent rated both cancer and other condition(s) as taking priority. Team complexity varied from low (32%), moderate (49%), and high (20%). Eighty percent rated PTE overall as high, with variation by subscales: coordination (85%) and patient-family focus (47%). Higher team complexity was associated with lower PTE overall (p=0.049). Challenges were identified: sequential referrals with no integration across team members; no shared mental model among team; and cancer survivor having to "referee" conflicting care decisions. CONCLUSION: This mixed method study found an inverse relationship between team complexity and PTE-overall, where high-complexity teams had lower team effectiveness. Participants reported issues with the problem-solving abilities of their teams and felt like their contributions were not valued by their care team. IMPLICATIONS FOR CANCER SURVIVORS: Improving team effectiveness offers one way to leverage the expertise of multiple specialties to deliver integrated, patient-centered care for the growing population of cancer survivors with MCC.

Climate Change Harm Perception Among U.S. Adults in the NCI Health Information National Trends Survey, 2022.

PURPOSE: To examine associations between 1) sociodemographics and 2) trust in health information sources with climate change harm perception. METHODS: Weighted adjusted logistic regression models examined correlates of climate change harm perception (harm vs no harm/don't know) among a nationally representative sample of U.S. adults (2022, n = 5585). RESULTS: Sixty-four percent of U.S. adults believed climate change will harm their health. College education (vs high school or less) (AOR 1.7, 95% CI 1.3, 2.2) and having greater trust in doctors (AOR 1.4, 95% CI 1.2, 1.7), scientists (aOR 1.8, 95% CI 1.6, 2.0), and government health agencies (AOR 1.7, 95% CI 1.5, 1.9) for health information were associated with believing climate change harms health. Conversely, greater trust in religious organizations was associated with 16% lower odds of believing climate change harms health (95% CI .74, .94). CONCLUSIONS: Climate change harm perception varied by sociodemographics and trust in health information source. Health communication delivered via alternative and diverse channels could expand the reach of climate and health messaging and ultimately increase public awareness and support for measures to mitigate the health impacts of climate change.

Clinical Multiteam System Composition and Complexity Among Newly Diagnosed Early-Stage Breast, Colorectal, and Lung Cancer Patients With Multiple Chronic Conditions: A SEER-Medicare Analysis.

PURPOSE: Sixty percent of adults have multiple chronic conditions at cancer diagnosis. These patients may require a multidisciplinary clinical team-of-teams, or a multiteam system (MTS), of high-complexity involving multiple specialists and primary care, who, ideally, coordinate clinical responsibilities, share information, and align clinical decisions to ensure comprehensive care needs are managed. However, insights examining MTS composition and complexity among individuals with cancer and comorbidities at diagnosis using US population-level data are limited. METHODS: Using SEER-Medicare data (2006-2016), we identified newly diagnosed patients with breast, colorectal, or lung cancer who had a codiagnosis of cardiopulmonary disease and/or diabetes (n = 75,201). Zaccaro's theory-based classification of MTSs was used to categorize clinical MTS complexity in the 4 months following cancer diagnosis: high-complexity (≥ 4 clinicians from ≥ 2 specialties) and low-complexity (1-3 clinicians from 1-2 specialties). We describe the proportions of patients with different MTS compositions and quantify the incidence of high-complexity MTS care by patient groups. RESULTS: The most common MTS composition was oncology with primary care (37%). Half (50.3%) received high-complexity MTS care. The incidence of high-complexity MTS care for non-Hispanic Black and Hispanic patients with cancer was 6.7% (95% CI, -8.0 to -5.3) and 4.7% (95% CI, -6.3 to -3.0) lower than non-Hispanic White patients with cancer; 13.1% (95% CI, -14.1 to -12.2) lower for rural residents compared with urban; 10.4% (95% CI, -11.2 to -9.5) lower for dual Medicaid-Medicare beneficiaries compared with Medicare-only; and 16.6% (95% CI, -17.5 to -15.8) lower for colorectal compared with breast cancer. CONCLUSION: Incidence differences of high-complexity MTS care were observed among cancer patients with multiple chronic conditions from underserved populations. The results highlight the need to further understand the effects of and mechanisms through which care team composition, complexity, and functioning affect care quality and outcomes.

Team-Based Care for Cancer Survivors With Comorbidities: A Systematic Review.

Coordination of quality care for the growing population of cancer survivors with comorbidities remains poorly understood, especially among health disparity populations who are more likely to have comorbidities at the time of cancer diagnosis. This systematic review synthesized the literature from 2000 to 2022 on team-based care for cancer survivors with comorbidities and assessed team-based care conceptualization, teamwork processes, and outcomes. Six databases were searched for original articles on adults with cancer and comorbidity, which defined care team composition and comparison group, and assessed clinical or teamwork processes or outcomes. We identified 1,821 articles of which 13 met the inclusion criteria. Most studies occurred during active cancer treatment and nine focused on depression management. Four studies focused on Hispanic or Black cancer survivors and one recruited rural residents. The conceptualization of team-based care varied across articles. Teamwork processes were not explicitly measured, but teamwork concepts such as communication and mental models were mentioned. Despite team-based care being a cornerstone of quality cancer care, studies that simultaneously assessed care delivery and outcomes for cancer and comorbidities were largely absent. Improving care coordination will be key to addressing disparities and promoting health equity for cancer survivors with comorbidities.

Thematic Analysis of Organizational Characteristics in NCI Community Oncology Research Program Cancer Care Delivery Research.

Organizational characteristics, including organizational structures and processes, are important to understanding care delivery and health outcomes. However, organizational-level constructs present measurement challenges in care delivery research. This analysis aims to understand if, when, and how organizational characteristics are examined in a National Cancer Institute (NCI) research network conducting cancer care delivery research (CCDR). The NCI Community Oncology Research Program encourages consideration of organizational variables in CCDR studies. We conducted a cross-sectional thematic analysis to identify organizational characteristics examined in this portfolio of research. Organizational characteristics targeted, related measures, and analytic approach were abstracted by 2 study investigators using a coding framework adapted from 2 existing frameworks. A total of 78.9% of eligible study protocols included organizational characteristics. Structural characteristics were the most common, collected in all 15 included protocols, 14 examined at least 1 organizational process, and 12 examined organizational-level outcomes. Most studies proposed descriptive practice-level analyses or multilevel analyses using random effects to account for clustering of patients and staff within practices. Few (n = 5) specified that organizational variables would be modeled as effects of interest (vs covaried out) or proposed analytic approaches that could more robustly examine effects of targeted organizational characteristics on primary outcomes. Inclusion of organizational variables is common in CCDR conducted through the NCI Community Oncology Research Program, NCI's national network charged with bringing cancer clinical trials to people in their communities. Nonetheless, opportunities remain to improve the use of theory to guide organizational construct selection, operationalization, measurement, and incorporation into study hypotheses and analyses.

Multilevel factors associated with inequities in multidisciplinary cancer consultation.

OBJECTIVE: To assess changes in the prevalence of multidisciplinary cancer consultations (MDCc) over the last decade and examine patient, surgeon, hospital, and neighborhood factors associated with receipt of MDCc among individuals diagnosed with cancer. DATA SOURCE: Surveillance, Epidemiology and End Results (SEER)-Medicare data from 2006 to 2016. STUDY DESIGN: We used time-series analysis to assess change in MDCc prevalence from 2007 to 2015. We also conducted multilevel logistic regression with random surgeon- and hospital-level effects to assess associations between patient, surgeon, neighborhood, and health care organization-level factors and receipt of MDCc during the cancer treatment planning phase, defined as the 2 months following cancer diagnosis. DATA COLLECTION/EXTRACTION METHODS: We identified Medicare beneficiaries >65 years of age with surgically resected breast, colorectal (CRC), or non-small cell lung cancer (NSCLC) stages I-III (n = 103,250). PRINCIPAL FINDINGS: From 2007 to 2015, the prevalence of MDCc increased from 35.0% to 61.2%. Overall, MDCc was most common among patients with breast cancer compared to CRC and NSCLC. Cancer patients who were Black, had comorbidities, had dual Medicare-Medicaid coverage, were residing in rural areas or in areas with higher Black and Hispanic neighborhood composition were significantly less likely to have received MDCc. Patients receiving surgery at disproportionate payment-sharing or rural-designated hospitals had 2% (95% CI: -3.55, 0.58) and 17.6% (95% CI: -21.45, 13.70), respectively, less probability of receiving MDCc. Surgeon- and hospital-level effects accounted for 15% of the variance in receipt of MDCc. CONCLUSIONS: The practice of MDCc has increased over the last decade, but significant geographical and health care organizational barriers continue to impede equitable access to and delivery of quality care across cancer patient populations. Multilevel and multicomponent interventions that target care coordination, health system, and policy changes may enhance equitable access to and receipt of MDCc.

Teamwork competencies for interprofessional cancer care in multiteam systems: A narrative synthesis.

Numerous teamwork competency frameworks are designed for co-located, procedure-driven teams delivering care in acute settings. Little is known about their applicability or evaluation among larger teams-of-teams, known as multiteam systems (MTS), involved in delivering care for complex chronic conditions like cancer. In this review we aimed to identify studies examining teamwork competencies or teamwork competency frameworks developed or tested in healthcare teams, identify the extent to which they have been applied or evaluated in cancer care, and understand their applicability to larger MTSs involved in coordinating cancer care. We identified 107 relevant original articles, consensus statements, and prior systematic reviews published from 2013-2019. Most original papers (n = 96) were intervention studies of inpatient acute care teams (52, 54%). Fifty-eight articles (60%) used existing frameworks to define competency domains. Four original articles and two consensus statements addressed teamwork competencies for cancer care. Few frameworks or interprofessional education (IPE) curricula specifically addressed teamwork among larger, distributed teams or examined competencies necessary to overcome care coordination challenges in cancer care MTSs. Research guiding the development of frameworks and IPE that consider challenges to effective coordination among larger MTSs and studies of their impact on patient and clinical outcomes is essential to optimal, high-quality care.

Opportunities for Cancer Health Care Disparities and Care Delivery Research: An Analysis of the NCI Health Care Delivery Research Program Portfolio.

Cancer health care disparities are complex, involve patient, clinician and health care system factors, and are defined as adverse differences in cancer outcomes. This analysis describes NCI's Healthcare Delivery Research Program's (HDRP) portfolio of disparities-focused research and identifies future research opportunities. Grants through HDRP (fiscal years 2012 to 2016) focused on detecting, understanding, and/or intervening on disparities in or among health disparity populations were reviewed by co-authors. Forty-eight funded grants were identified, coded, and characterized. Descriptive analyses are reported. Most studies focused on racial/ethnic minorities and socioeconomically disadvantaged groups. Colorectal, breast, and cervical cancers were most frequently examined. Almost 40% of studies addressed the intervening phase of the disparities research continuum. Few studies focused on clinician-level factors or involved the community in the research design. A sustained disparities research emphasis is essential to addressing the determinants of and cancer burden among health disparity populations across the cancer care continuum.

Delivery of Financial Navigation Services Within National Cancer Institute-Designated Cancer Centers.

Background: Cancer centers have a responsibility to help patients manage the costs of their cancer treatment. This article describes the availability of financial navigation services within the National Cancer Institute (NCI)-designated cancer centers. Methods: Data were obtained from the NCI Survey of Financial Navigation Services and Research, an online survey administered to NCI-designated cancer centers from July to September 2019. Of the 62 eligible centers, 57 completed all or most of the survey, for a response rate of 90.5%. Results: Nearly all cancer centers reported providing help with applications for pharmaceutical assistance programs and medical discounts (96.5%), health insurance coverage (91.2%), assistance with nonmedical costs (96.5%), and help understanding medical bills and out-of-pocket costs (85.9%). Although other services were common, in some cases they were only available to certain patients. These services included direct financial assistance with medical and nonmedical costs and referrals to outside organizations for financial assistance. The least common services included medical debt management (63.2%), detailed discussions about the cost of treatment (54.4%), and guidance about legal protections (50.1%). Providing treatment cost transparency to patients was reported as a common challenge: 71.9% of centers agreed or strongly agreed that it is difficult to determine how much a cancer patient's treatment will cost, and 70.2% of oncologists are reluctant to discuss financial issues with patients. Conclusions: Cancer centers provide many financial services and resources. However, there remains a need to build additional capacity to deliver comprehensive financial navigation services and to understand the extent to which patients are referred and helped by these services.

Perceptions of care coordination among older adult cancer survivors: A SEER-CAHPS study.

OBJECTIVE: Care coordination reflects deliberate efforts to harmonize patient care. This study examined variables associated with patient-reported care coordination scores among Medicare beneficiaries with a history of cancer. METHODS: We utilized Surveillance, Epidemiology, and End Results-Consumer Assessment of Healthcare Providers and Systems (SEER-CAHPS) linked data, which includes cancer registry data, patient experience surveys, and Medicare claims. We identified Medicare beneficiaries with a CAHPS survey ≤10 years after cancer diagnosis who reported seeing a personal doctor within six months. Multivariable regression models examined associations between cancer survivor characteristics and patient-reported care coordination, with higher scores indicating better coordination. RESULTS: Cancer site distribution of the 14,646 survey respondents was 33.7% prostate, 22.1% breast, 11.1% colorectal, 7.2% lung, and 25.9% other. Rural residence at diagnosis (versus urban, 1.1-point difference; p = 0.04) and reporting >4 visits with a personal doctor (versus 1-2 visits, 3.0-point difference; p < 0.001) were significantly associated with higher care coordination. Older age (p < 0.001) and seeing more specialists (p = 0.006) were associated with significantly lower care coordination. Patients with melanoma (women: 5.2-point difference, p < 0.001; men: 2.7 points, p = 0.01) or breast cancer (women: 2.4 points; p < 0.001) reported significantly lower care coordination scores than did men with prostate cancer (reference group). Time from diagnosis to survey, cancer stage, number of cancers, and comorbidities were not significantly associated with care coordination scores. DISCUSSION: Cancer site, rural residence, and number of physician interactions are associated with patient-reported care coordination scores. Future research should address multilevel influences that lead to worse care coordination for older adult cancer survivors.

The Anatomy and Physiology of Teaming in Cancer Care Delivery: A Conceptual Framework.

Care coordination challenges for patients with cancer continue to grow as expanding treatment options, multimodality treatment regimens, and an aging population with comorbid conditions intensify demands for multidisciplinary cancer care. Effective teamwork is a critical yet understudied cornerstone of coordinated cancer care delivery. For example, comprehensive lung cancer care involves a clinical "team of teams"-or clinical multiteam system (MTS)-coordinating decisions and care across specialties, providers, and settings. The teamwork processes within and between these teams lay the foundation for coordinated care. Although the need to work as a team and coordinate across disciplinary, organizational, and geographic boundaries increases, evidence identifying and improving the teamwork processes underlying care coordination and delivery among the multiple teams involved remains sparse. This commentary synthesizes MTS structure characteristics and teamwork processes into a conceptual framework called the cancer MTS framework to advance future cancer care delivery research addressing evidence gaps in care coordination. Included constructs were identified from published frameworks, discussions at the 2016 National Cancer Institute-American Society of Clinical Oncology Teams in Cancer Care Workshop, and expert input. A case example in lung cancer provided practical grounding for framework refinement. The cancer MTS framework identifies team structure variables and teamwork processes affecting cancer care delivery, related outcomes, and contextual variables hypothesized to influence coordination within and between the multiple clinical teams involved. We discuss how the framework might be used to identify care delivery research gaps, develop hypothesis-driven research examining clinical team functioning, and support conceptual coherence across studies examining teamwork and care coordination and their impact on cancer outcomes.

Identifying Cancer Care Team Competencies to Improve Care Coordination in Multiteam Systems: A Modified Delphi Study.

PURPOSE: Identifying nontechnical, teamwork competencies (knowledge, skills, and attitudes) underlying coordination within and across the network of teams-or multiteam system (MTS) involved in cancer care is foundational to optimizing high-quality cancer care. METHODS: A multidisciplinary group of cancer care stakeholders refined an initial list of competency statements during three rounds of a web-based modified Delphi survey. RESULTS: Panelists reached consensus on a final list of four domains and 20 associated team-based competencies important for effective coordination in cancer care MTS. CONCLUSION: This study provides an initial foundation for testing, modifying, measuring and evaluating the impact of identified competencies on care coordination, outcomes, and costs, for people being screened, treated, or surviving cancer.

Advancing Rural Cancer Control Research: National Cancer Institute Efforts to Identify Gaps and Opportunities.

Cancer mortality rates are approximately 8% higher in rural populations and mortality rates are falling more slowly in rural communities, resulting in widening rural-urban health disparities in the United States. The NCI has a long history of supporting health disparities research, including research to understand the health needs, strengths, and opportunities in rural communities. However, the portfolio analysis described in this article underscores the need to significantly accelerate rural cancer control research in partnership with state and local communities. This commentary outlines NCI's efforts over the last four years to address gaps in rural cancer control research and improve cancer prevention, control, and care delivery in rural populations. Future directions, challenges, and opportunities are also discussed.

Perceptions of Facilitators and Barriers to Measuring and Improving Quality in Palliative Care Programs.

OBJECTIVE: To examine perceptions of facilitators and barriers to quality measurement and improvement in palliative care programs and differences by professional and leadership roles. METHODS: We surveyed team members in diverse US and Canadian palliative care programs using a validated survey addressing teamwork and communication and constructs for educational support and training, leadership, infrastructure, and prioritization for quality measurement and improvement. We defined key facilitators as constructs rated ≥4 (agree) and key barriers as those ≤3 (disagree) on 1 to 5 scales. We conducted multivariable linear regressions for associations between key facilitators and barriers and (1) professional and (2) leadership roles, controlling for key program and respondent factors and clustering by program. RESULTS: We surveyed 103 respondents in 11 programs; 45.6% were physicians and 50% had leadership roles. Key facilitators across sites included teamwork, communication, the implementation climate (or environment), and program focus on quality improvement. Key barriers included educational support and incentives, particularly for quality measurement, and quality improvement infrastructure such as strategies, systems, and skilled staff. In multivariable analyses, perceptions did not differ by leadership role, but physicians and nurse practitioners/nurses/physician assistants rated most constructs statistically significantly more negatively than other team members, especially for quality improvement (6 of the 7 key constructs). CONCLUSIONS: Although participants rated quality improvement focus and environment highly, key barriers included lack of infrastructure, especially for quality measurement. Building on these facilitators and measuring and addressing these barriers might help programs enhance palliative care quality initiatives' acceptability, particularly for physicians and nurses.

Managing creativity and compliance in the pursuit of patient safety.

BACKGROUND: Are creativity and compliance mutually exclusive? In clinical settings, this question is increasingly relevant. Hospitals and clinics seek the creative input of their employees to help solve persistent patient safety issues, such as the prevention of bloodstream infections, while simultaneously striving for greater adherence to evidence-based guidelines and protocols. Extant research provides few answers about how creativity works in such contexts. METHODS: Cross-sectional survey data were collected from employees in 24 different U.S.-based outpatient hemodialysis clinics. Linear mixed-effects models were utilized to test study hypotheses. Professional status, clinic climate variables, and interaction terms were modeled as fixed effects, with a random effect for clinic included in all models. RESULTS: Our results show that high status employees contributed more creative patient safety improvement ideas compared to low status employees. However, when high status employees were part of clinics with a stronger safety climate of compliance, they contributed fewer creative ideas compared to their counterparts working in clinics with a reduced compliance orientation. We also predicted low status employees working in less punitive clinics would contribute more creative ideas, but this hypothesis was not fully supported. CONCLUSIONS: This study suggests that in hospitals and clinics that rely on strict protocols and formal hierarchies to meet their goals, the factors that promote creativity may be distinctively context-dependent. Implications for theory, practice, as well as future directions for research examining creativity in healthcare and safety critical contexts are discussed.

Manifestations of High-Reliability Principles on Hospital Units With Varying Safety Profiles: A Qualitative Analysis.

BACKGROUND: To prevent patient harm, health care organizations are adopting practices from other complex work environments known as high-reliability organizations (HRO). PURPOSE: The purpose was to explore differences in manifestations of HRO principles on hospital units with high and low safety performance. METHODS: Focus groups were conducted on units scoring high or low on safety measures. Themes were identified using a grounded theory approach, and responses were compared using qualitative thematic analysis. RESULTS: High performers indicated proactive responses to safety issues and expressed understanding of systems-based errors, while low performers were more reactive and often focused on individual education to address issues. Both groups experienced communication challenges, although they employed different methods of speaking up. CONCLUSION: Some HRO principles were present in the language used by our participants. High performers exhibited greater manifestations of HRO, although HRO alone was insufficient to describe our results. Mindful organizing, which expands on HRO, was a better fit.