Factors influencing middle managers' commitment to the implementation of innovations in cancer care.

OBJECTIVE: To identify and illuminate influences on middle managers' commitment to innovation implementation. METHODS: A qualitative study was conducted, employing the methods of grounded theory. Semi-structured interviews were used to collect data from middle managers (n = 15) in Nova Scotia and New Brunswick, Canada. Data were collected and analysed concurrently, using an inductive constant comparative approach. Data collection and analysis continued until theoretical saturation was reached. RESULTS: The data revealed middle managers contemplate two central issues in terms of their commitment to implementation, that is whether or not they fully engage in and support the implementation of a particular innovation. These issues are (1) ease of implementation and (2) potential benefit for patients. Middle managers' views and expectations related to ease of implementation are influenced by available resources, fit with setting, and stakeholder buy-in. Their views on patient benefit are influenced by external evidence of benefit and local gaps in care. CONCLUSIONS: These findings provide further insight into the factors that influence middle managers' commitment to innovation implementation, and how middle managers consider these factors in the context of their work settings.

Making It Happen: Middle Managers' Roles in Innovation Implementation in Health Care.

BACKGROUND: Middle managers are given scant attention in the implementation literature in health care, where the focus is on senior leaders and frontline clinicians. AIMS: To empirically examine the role of middle managers relevant to innovation implementation and how middle managers experience the implementation process. METHODS: A qualitative study was conducted using the methods of grounded theory. Data were collected through semistructured interviews with middle managers (N = 15) in Nova Scotia and New Brunswick, Canada. Participants were purposively sampled, based on their involvement in implementation initiatives and to obtain variation in manager characteristics. Data were collected and analyzed concurrently, using an inductive constant comparative approach. Data collection and analysis continued until theoretical saturation was reached. RESULTS: Middle managers see themselves as being responsible for making implementation happen in their programs and services. As a result, they carry out five roles related to implementation: planner, coordinator, facilitator, motivator, and evaluator. However, the data also revealed two determinants of middle managers' role in implementation, which they must negotiate to fulfill their specific implementation roles and activities: (1) They perform many other roles and responsibilities within their organizations, both clinical and managerial in nature, and (2) they have limited decision-making power with respect to implementation and must work within the parameters set by upper levels of the organization. LINKING EVIDENCE TO ACTION: Middle managers play an important role in translating adoption decisions into on-the-ground implementation. Optimizing their capacity to fulfill this role may be key to improving innovation implementation in healthcare organizations.

Population-based longitudinal study of follow-up care for patients with colorectal cancer in Nova Scotia.

PURPOSE: The purpose of this study was to examine colorectal cancer (CRC) follow-up care in Nova Scotia, Canada. More specifically, the objectives were to describe adherence to two elements of follow-up guidelines (colonoscopies and physician visits) and to identify factors associated with receiving at least guideline-recommended care. METHODS: All patients with stage II or III CRC undergoing curative-intent surgery in Nova Scotia, Canada, were identified through the provincial cancer registry and anonymously linked to additional administrative health databases. For a 3-year follow-up period, beginning 1 year after the diagnosis date, descriptive statistics were calculated for physician visits and colonoscopies. Factors associated with receiving at least guideline-recommended care were identified using logistic regression. RESULTS: Most patients received follow-up care from multiple physician specialties. In year 3, 58.1% of patients received oncologist follow-up care. Guideline adherence for colonoscopies was 52.4%, whereas guideline adherence for physician visits decreased from 41.9% to 25.4%. Receipt of at least guideline-recommended care was inversely associated with age and comorbidity for colonoscopy and inversely associated with age for physician visits. CONCLUSION: Receipt of follow-up care from oncologists and primary care physicians, prolonged oncologist care, and receipt of care inconsistent with guideline recommendations suggest there may be potential issues with inefficient use of cancer system resources and integration of guidelines into follow-up care practices in Nova Scotia. Transitioning routine follow-up to primary care could potentially increase guideline adherence by improving access to and continuity of care. CRC may be well suited to targeted knowledge translation strategies to improve guideline adherence.

Evaluating survivorship care plans: results of a randomized, clinical trial of patients with breast cancer.

PURPOSE: An Institute of Medicine report recommends that patients with cancer receive a survivorship care plan (SCP). The trial objective was to determine if an SCP for breast cancer survivors improves patient-reported outcomes. PATIENTS AND METHODS: Women with early-stage breast cancer who completed primary treatment at least 3 months previously were eligible. Consenting patients were allocated within two strata: less than 24 months and ≥ 24 months since diagnosis. All patients were transferred to their own primary care physician (PCP) for follow-up. In addition to a discharge visit, the intervention group received an SCP, which was reviewed during a 30-minute educational session with a nurse, and their PCP received the SCP and guideline on follow-up. The primary outcome was cancer-related distress at 12 months, assessed by the Impact of Event Scale (IES). Secondary outcomes included quality of life, patient satisfaction, continuity/coordination of care, and health service measures. RESULTS: Overall, 408 survivors were enrolled through nine tertiary cancer centers. There were no differences between groups on cancer-related distress or on any of the patient-reported secondary outcomes, and there were no differences when the two strata were analyzed separately. More patients in the intervention than control group correctly identify their PCP as primarily responsible for follow-up (98.7% v 89.1%; difference, 9.6%; 95% CI, 3.9 to 15.9; P = .005). CONCLUSION: The results do not support the hypothesis that SCPs are beneficial for improving patient-reported outcomes. Transferring follow-up to PCPs is considered an important strategy to meet the demand for scarce oncology resources. SCPs were no better than a standard discharge visit with the oncologist to facilitate transfer.

Do available questionnaires measure the communication factors that patients and families consider important at end of life?

Patients with advanced cancer report wanting better communication. Our previous research identified five specific communication domains important to end-of-life (EOL) cancer care: communicating information, interpersonal communication, communicating available supportive care services, communicating a transition in the objectives of care, and interprofessional communication. A literature review was conducted to identify patient-, family member-, or heath professional-reported questionnaires to measure these specific communication domains. On the basis of specific criteria, including validity and evidence base, 10 questionnaires were identified that have the potential to measure and monitor the quality of communication during EOL cancer care. No single questionnaire measured all five domains. There is a need to further develop questionnaires that have the capacity to specifically measure those communication domains that are important to patients with cancer and their families at EOL.

Are leading medical journals following their own policies on CONSORT reporting?

The revised Consolidated Standards of Reporting Trials (CONSORT) statement recognizes the importance of including data so that readers are able to judge the reliability or relevance of randomized controlled trial (RCT) findings. However, it is unclear whether journals consistently report the pre-randomization information necessary to assess the general applicability of trial results. The objective of this study was to assess the extent of adherence to pre-randomization data reporting in 4 leading general medicine journals, as recommended by the revised CONSORT statement over a specific time frame. A total of 480 RCTs met the eligibility criteria for review. In 2004, 138 of 246 (56%) articles reported the full CONSORT pre-randomization information, of which 121 (88%) presented this information in diagram form. In 2006, 136 of 234 (58%) reported the full information, of which 127 (93%) presented the information in a diagram. These numbers indicate no improvement in the reporting of pre-randomization information. In conclusion, reporting of the full CONSORT data remains inconsistent. We recommend that journals continue to support the CONSORT statement and ensure that adequate information is provided upon submission before commencing the peer review process. The presentation of clear, precise data will ensure that readers are able to better interpret the applicability of findings.

Toward population-based indicators of quality end-of-life care: testing stakeholder agreement.

BACKGROUND: Quality indicators (QIs) are tools designed to measure and improve quality of care. The objective of this study was to assess stakeholder acceptability of QIs of end-of-life (EOL) care that potentially were measurable from population-based administrative health databases. METHODS: After a literature review, the authors identified 19 candidate QIs that potentially were measurable through administrative databases. A modified Delphi methodology, consisting of multidisciplinary panels of cancer care health professionals in Nova Scotia and Ontario, was used to assess agreement on acceptable QIs of EOL care (n = 21 professionals; 2 panels per province). Focus group methodology was used to assess acceptability among patients with metastatic breast cancer (n = 16 patients; 2 groups per province) and bereaved family caregivers of women who had died of metastatic breast cancer (n = 8 caregivers; 1 group per province). All sessions were audiotaped, transcribed verbatim, and audited, and thematic analyses were conducted. RESULTS: Through the Delphi panels, 10 QIs and 2 QI subsections were identified as acceptable indicators of quality EOL care, including those related to pain and symptom management, access to care, palliative care, and emergency room visits. When Delphi panelists did not agree, the principal reasons were patient preferences, variation in local resources, and benchmarking. In the focus groups, patients and family caregivers also highlighted the need to consider preferences and local resources when examining quality EOL care. CONCLUSIONS: The findings of this study should be considered when developing quality monitoring systems. QIs will be most useful when stakeholders perceive them as measuring quality care.

Breast Cancer Guidelines in Canada: A Review of Development and Implementation.

A series of specific clinical practice guidelines (CPGs) were published in Canada in 1998. A primary objective of these 'Clinical Practice Guidelines for the Care and Treatment of Breast Cancer' was to decrease the variation in breast cancer care across the country. Prior to this, researchers found moderate compliance with consensus recommendations for breast cancer therapies in several Canadian provinces. However, a recent study concluded that the publication of the Canadian CPGs did not reduce variations in surgical care for breast cancer. If guidelines are to achieve their intended objectives, they must be implemented in ways that support, encourage, and facilitate their use. Evidence strongly suggests the simple publication and passive dissemination of CPGs are usually ineffective in changing how physicians actually care for patients. CPG implementation, therefore, requires active knowledge translation processes to ensure that the evidence is relevant to all with a stake in bettering breast cancer care. For example, implementation strategies that use computerized CPGs can make evidence-based decision-making routine practice in the clinical setting. The breast cancer community can also work with the newly formed Canadian Partnership Against Cancer to find ways to more successfully support and facilitate guideline use considering the local context.