Surgeon and Care Team Network Measures and Timely Breast Cancer Treatment.

Importance: Cancer treatment delay is a recognized marker of worse outcomes. Timely treatment may be associated with physician patient-sharing network characteristics, yet this remains understudied. Objective: To examine the associations of surgeon and care team patient-sharing network measures with breast cancer treatment delay. Design, Setting, and Participants: This cross-sectional study of Medicare claims in a US population-based setting was conducted from 2017 to 2020. Eligible participants included patients with breast cancer who received surgery and the subset who went on to receive adjuvant therapy. Patient-sharing networks were constructed for treating physicians. Data were analyzed from September 2023 to February 2024. Exposures: Surgeon linchpin score (a measure of local uniqueness or scarcity) and care density (a measure of physician team familiarity) were assessed. Surgeons were considered linchpins if their linchpin score was in the top 15%. The care density of a patient's physician team was calculated on preoperative teams for surgically-treated patients and postoperative teams for adjuvant therapy-receiving patients. Main Outcomes and Measures: The primary outcomes were surgical and adjuvant delay, which were defined as greater than 60 days between biopsy and surgery and greater than 60 days between surgery and adjuvant therapy, respectively. Results: The study cohort included 56 433 patients (18 004 aged 70-74 years [31.9%]) who were mostly from urban areas (44 931 patients [79.6%]). Among these patients, 8009 (14.2%) experienced surgical delay. Linchpin surgeon status (locally unique surgeon) was not statistically associated with surgical delay; however, patients with high preoperative care density (ie, high team familiarity) had lower odds of surgical delay compared with those with low preoperative care density (odds ratio [OR], 0.58; 95% CI, 0.53-0.63). Of the 29 458 patients who received adjuvant therapy after surgery, 5700 (19.3%) experienced adjuvant delay. Patients with a linchpin surgeon had greater odds of adjuvant delay compared with those with a nonlinchpin surgeon (OR, 1.30; 95% CI, 1.13-1.49). Compared with those with low postoperative care density, there were lower odds of adjuvant delay for patients with high postoperative care density (OR, 0.77; 95% CI, 0.69-0.87) and medium postoperative care density (OR, 0.85; 95% CI, 0.77-0.94). Conclusions and Relevance: In this cross-sectional study of Medicare claims, network measures capturing physician scarcity and team familiarity were associated with timely treatment. These results may help guide system-level interventions to reduce cancer treatment delays.

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.

Single chloroplast in folio imaging sheds light on photosystem energy redistribution during state transitions.

Oxygenic photosynthesis is driven by light absorption in photosystem I (PSI) and photosystem II (PSII). A balanced excitation pressure between PSI and PSII is required for optimal photosynthetic efficiency. State transitions serve to keep this balance. If PSII is overexcited in plants and green algae, a mobile pool of light-harvesting complex II (LHCII) associates with PSI, increasing its absorption cross-section and restoring the excitation balance. This is called state 2. Upon PSI overexcitation, this LHCII pool moves to PSII, leading to state 1. Whether the association/dissociation of LHCII with the photosystems occurs between thylakoid grana and thylakoid stroma lamellae during state transitions or within the same thylakoid region remains unclear. Furthermore, although state transitions are thought to be accompanied by changes in thylakoid macro-organization, this has never been observed directly in functional leaves. In this work, we used confocal fluorescence lifetime imaging to quantify state transitions in single Arabidopsis (Arabidopsis thaliana) chloroplasts in folio with sub-micrometer spatial resolution. The change in excitation-energy distribution between PSI and PSII was investigated at a range of excitation wavelengths between 475 and 665 nm. For all excitation wavelengths, the PSI/(PSI + PSII) excitation ratio was higher in state 2 than in state 1. We next imaged the local PSI/(PSI + PSII) excitation ratio for single chloroplasts in both states. The data indicated that LHCII indeed migrates between the grana and stroma lamellae during state transitions. Finally, fluorescence intensity images revealed that thylakoid macro-organization is largely unaffected by state transitions. This single chloroplast in folio imaging method will help in understanding how plants adjust their photosynthetic machinery to ever-changing light conditions.

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.

Multiteam Systems in Long Duration Exploration Missions: A Qualitative Analysis of Key Characteristics and Challenges.

Given the unprecedented environment of long duration space exploration (LDSE), success simply cannot occur without the coordinated efforts of multiple teams, both in flight and on the ground. These multiteam systems (MTSs) are needed to achieve the complex and dynamic tasks of spaceflight missions that will be longer and more uncertain than any previously experienced. Accordingly, research is limited in terms of how to best coordinate these teams and their dynamics-and in particular, how to best prepare LDSE teams to work across time and space effectively. To begin to address these critical questions systematically, qualitative data was extracted from a series of ten interviews with experts in spaceflight and long duration analog environments. Using thematic analysis techniques, we identified several consistent themes for affective, behavioral, and cognitive elements of teamwork occurring within and between teams. We examine each of these in detail, to identify the dynamics of what is currently known and where research needs to go to provide guidance for spaceflight organizations as well as others attempting to successfully implement MTSs in novel, complex environments.

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.

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.

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.

Team training in obstetrics: A multi-level evaluation.

INTRODUCTION: Obstetric complications and adverse patient events are often preventable. Teamwork and situational awareness (SA) can improve detection and coordination of critical obstetric (OB) emergencies, subsequently improving decision making and patient outcomes. The purpose of this study was to assess the effectiveness of a team training intervention in improving learning and transfer of teamwork, SA, decision making, and cognitive bias as well as patient outcomes in OB. METHOD: An adapted TeamSTEPPS training program was delivered to OB clinicians. Training targeted communication, mutual support, situation monitoring, leadership, SA, and cognitive bias. We conducted a repeated measures multilevel evaluation of the training using Kirkpatrick's (1994) framework of training evaluation to determine impact on trainee reactions, learning, transfer, and results. Data were collected using surveys, situational judgment tests (SJTs), observations, and patient chart reviews. RESULTS: Participants perceived the training as useful. Additionally, participants acquired knowledge of communication strategies, though knowledge of other team competencies did not significantly improve nor did self-reported teamwork on the unit. Although SJT decision accuracy did not significantly improve for all scenarios, results of behavioral observation suggest that decision accuracy significantly improved on the job, and there was a marginally significant reduction in babies' hospital length of stay. DISCUSSION: These findings indicate that the training intervention was partially effective, but more work needs to be done to determine the conditions under which training is most effective, and the ways in which to sustain improvements. Future research is needed to confirm its generalizability to additional OB units and departments.