Primary Care Provider Visits Among Cancer Survivors 5-7 Years Postdiagnosis.

PURPOSE: Cancer survivors experience better outcomes when primary care providers (PCPs) are engaged in their care. Nearly all survivors have a PCP engaged in their care in the initial 5 years postdiagnosis, but little is known about sustained PCP engagement. We assessed PCP engagement in survivors' care 5-7 years postdiagnosis and characterized survivors most vulnerable to loss to PCP follow-up. METHODS: We linked electronic health record ambulatory care and cancer registry data from an National Cancer Institute-Designated Comprehensive Cancer Center to identify eligible survivors (≥18 years; diagnosed with breast, colorectal, or uterine cancer; had an in-network PCP). We used multiple logistic regression to assess associations between survivor demographics, clinical factors, and health care utilization and odds of sustained PCP engagement. RESULTS: In 5-7 years postdiagnosis, PCPs were engaged in care for 43% of survivors. Survivors with sustained PCP-engagement were on average 4.6 years older than those without (P < .0001); survivors had 1.36 greater odds of having regular PCP visits for each decade increase in age on cancer diagnosis (P = .0030). Survivors were less likely to be lost to PCP follow-up if diagnosed at an earlier stage with odds at 0.57 and 0.10 for stage I and stage IV, respectively (P = .0005), and had 2.70 greater odds of engagement in care with at least one oncology visit annually 5-7 years postdiagnosis (P < .0001). CONCLUSION: Sustained PCP engagement is endorsed as critical by survivors, PCPs, and oncologists. We found most survivors were lost to PCP follow-up 5-7 years postdiagnosis. Our study is among the first to contribute empirical evidence of survivors being lost in transition. Findings from this study demonstrate the need to bridge gaps in long-term care for cancer survivors.

Physician perspectives on clinician-to-clinician telemedical consultation for gynecologic cancers: A qualitative study.

Objective: Approximately fifteen million women in the United States live > 50 miles from a gynecologic oncologist. Telemedical technology allows patients' local physicians to consult with subspecialist gynecologic oncologists without burdening patients with unnecessary in-person visits. Although critical to adoption of this technology, physicians' input into implementation of clinician-to-clinician consultation has not been sought. We therefore gathered feedback about experiences with referrals, communication, and openness to telemedical consultation from gynecologic oncologists, gynecologists, and medical oncologists. Methods: We recruited gynecologic oncologists, gynecologists, and medical oncologists from practices serving rural patients to participate in semi-structured interviews. The Consolidated Framework for Implementation Research and the Theoretical Domains Framework guided the interviews. Questions focused on factors influencing adoption and implementation of clinician-to-clinician telemedicine. Interviews were conducted via WebEx, recorded, and transcribed. Two investigators coded interviews using the combined frameworks and identified salient themes. Results: We conducted 11 interviews (6 gynecologic oncologists, 3 gynecologists, 2 medical oncologists) and identified themes encompassing communication burnout, barriers to sharing patient information, need for further logistical information, and potential benefits to patients. Conclusions: Clinician-to-clinician telemedicine may improve access to gynecologic cancer care by decreasing barriers to subspecialty expertise while simultaneously benefiting referring and consultant clinicians through improved identification and workup of patients who may need in-person consultation. To optimize desired outcomes, telemedical consultation must allow for communication of relevant patient information and records and easy integration into clinical workflow. Importantly, clinicians must perceive the consultation as improving patients' access to specialty care.

Toward a more comprehensive understanding of organizational influences on implementation: the organization theory for implementation science framework.

Introduction: Implementation is influenced by factors beyond individual clinical settings. Nevertheless, implementation research often focuses on factors related to individual providers and practices, potentially due to limitations of available frameworks. Extant frameworks do not adequately capture the myriad organizational influences on implementation. Organization theories capture diverse organizational influences but remain underused in implementation science. To advance their use among implementation scientists, we distilled 70 constructs from nine organization theories identified in our previous work into theoretical domains in the Organization Theory for Implementation Science (OTIS) framework. Methods: The process of distilling organization theory constructs into domains involved concept mapping and iterative consensus-building. First, we recruited organization and implementation scientists to participate in an online concept mapping exercise in which they sorted organization theory constructs into domains representing similar theoretical concepts. Multidimensional scaling and hierarchical cluster analyses were used to produce visual representations (clusters) of the relationships among constructs in concept maps. Second, to interpret concept maps, we engaged members of the Cancer Prevention and Control Research Network (CPCRN) OTIS workgroup in consensus-building discussions. Results: Twenty-four experts participated in concept mapping. Based on resulting construct groupings' coherence, OTIS workgroup members selected the 10-cluster solution (from options of 7-13 clusters) and then reorganized clusters in consensus-building discussions to increase coherence. This process yielded six final OTIS domains: organizational characteristics (e.g., size; age); governance and operations (e.g., organizational and social subsystems); tasks and processes (e.g., technology cycles; excess capacity); knowledge and learning (e.g., tacit knowledge; sense making); characteristics of a population of organizations (e.g., isomorphism; selection pressure); and interorganizational relationships (e.g., dominance; interdependence). Discussion: Organizational influences on implementation are poorly understood, in part due to the limitations of extant frameworks. To improve understanding of organizational influences on implementation, we distilled 70 constructs from nine organization theories into six domains. Applications of the OTIS framework will enhance understanding of organizational influences on implementation, promote theory-driven strategies for organizational change, improve understanding of mechanisms underlying relationships between OTIS constructs and implementation, and allow for framework refinement. Next steps include testing the OTIS framework in implementation research and adapting it for use among policymakers and practitioners.