A Patient Decision Aid for Men With Localized Prostate Cancer: A Comparative Case Study of Natural Implementation Approaches.

BACKGROUND: There are multiple options for men diagnosed with localized prostate cancer. Patient decision aids (PtDAs) help empower individuals and reduce unwarranted practice variation, but few are used in clinical practice. OBJECTIVE: We compared 2 programs implementing PtDAs for men with localized prostate cancer. METHODS: This was a comparative case study. Case 1 was a hospital prostate pathway and case 2 was a provincial prostate pathway with 2 locations (2a, 2b). Nurses provided the men with PtDAs and answered questions. Data sources were as follows: (a) 2 years administrative data for men with localized prostate cancer, (b) clinicians survey and interviews, and (c) patients/spouses interviews. Analysis was within and across cases. RESULTS: The PtDA was used with 23% of men in case 1 (95% confidence interval, 19.8%-26.1%) and 98% of men in case 2a (95% confidence interval, 96.5%-99.8%). The pathway was not implemented in case 2b. Men given the PtDA had positive experiences. Many clinicians supported the use of PtDAs, some adapted their discussions with patients, and others did not support the use of PtDAs. To increase use in case 1, participants identified needing a Canadian PtDA available electronically and endorsed by all clinicians. In case 2b, the provincial prostate pathway needed to be implemented. CONCLUSIONS: There was variable uptake of the PtDAs between the cases. Men who received the PtDA had positive outcomes. Several strategies were identified to increase or sustain PtDA use. IMPLICATIONS FOR PRACTICE: Nurses have a key role in supporting men making decisions about prostate cancer treatment by providing PtDAs, answering questions, and advocating for men's preferences.

How do organisational characteristics influence teamwork and service delivery in lung cancer diagnostic assessment programmes? A mixed-methods study.

OBJECTIVES: Diagnostic assessment programmes (DAPs) can reduce wait times for cancer diagnosis, but optimal DAP design is unknown. This study explored how organisational characteristics influenced multidisciplinary teamwork and diagnostic service delivery in lung cancer DAPs. DESIGN: A mixed-methods approach integrated data from descriptive qualitative interviews and medical record abstraction at 4 lung cancer DAPs. Findings were analysed with the Integrated Team Effectiveness Model. SETTING: 4 DAPs at 2 teaching and 2 community hospitals in Canada. PARTICIPANTS: 22 staff were interviewed about organisational characteristics, target service benchmarks, and teamwork processes, determinants and outcomes; 314 medical records were reviewed for actual service benchmarks. RESULTS: Formal, informal and asynchronous team processes enabled service delivery and yielded many perceived benefits at the patient, staff and service levels. However, several DAP characteristics challenged teamwork and service delivery: referral volume/workload, time since launch, days per week of operation, rural-remote population, number and type of full-time/part-time human resources, staff colocation, information systems. As a result, all sites failed to meet target benchmarks (from referral to consultation median 4.0 visits, median wait time 35.0 days). Recommendations included improved information systems, more staff in all specialties, staff colocation and expanded roles for patient navigators. Findings were captured in a conceptual framework of lung cancer DAP teamwork determinants and outcomes. CONCLUSIONS: This study identified several DAP characteristics that could be improved to facilitate teamwork and enhance service delivery, thereby contributing to knowledge of organisational determinants of teamwork and associated outcomes. Findings can be used to update existing DAP guidelines, and by managers to plan or evaluate lung cancer DAPs. Ongoing research is needed to identify ideal roles for navigators, and staffing models tailored to case volumes.

Implementation of a patient decision aid for men with localized prostate cancer: evaluation of patient outcomes and practice variation.

BACKGROUND: Men with localized prostate cancer often have unrealistic expectations. Practitioners are poor judges of men's preferences, contributing to preference misdiagnosis and unwarranted practice variation. Patient decision aids (PtDAs) can support men with decisions about localized prostate cancer. This is a comparative case study of two strategies for implementing PtDAs in clinical pathways for men with localized prostate cancer, evaluating (a) PtDA use; (b) impact on men, practitioners, and health system outcomes; and (c) factors influencing sustained use. METHODS/DESIGN: Guided by the Knowledge to Action Framework, this comparative case study will be conducted using administrative data, interviews, and surveys. Cases will be bound by geographic location (one hospital in Ontario; province of Saskatchewan) and time. Eligible participants will be all men newly diagnosed with localized prostate cancer, with outcomes assessed using administrative data and interviews. Nurses, urologists, radiation oncologists, and managers will be surveyed and a smaller sample interviewed. Cases will be established for each setting with findings compared across cases. Changes in the proportions of men given the PtDA over 2 years will be determined from administrative data. Factors associated with receiving the PtDA will be explored using multivariable logistic regression analysis. To assess the impact of the PtDA, outcomes will be described using mean and standard deviation (men's decisional conflict) and frequency and proportions (practitioners consulted, uptake of treatment). To estimate the effect of the PtDA on these outcomes, adjusted mean differences and odds ratios will be calculated using exploratory multivariable general linear regression and binary or multinomial logistic regression. Factors influencing sustained PtDA use will be assessed using descriptive analysis of survey findings and thematic analysis of interview transcripts. DISCUSSION: Determining how to embed PtDAs effectively within clinical pathways for men with localized prostate cancer is essential. PtDAs have the potential to strengthen men's active role in making prostate cancer decisions, enhance uptake of shared decision-making by practitioners, and reduce practice variation. Our team of researchers and knowledge users will use findings to improve current PtDA use and consider scaling-up implementation.

Improving breast diagnostic services with a Rapid Access Diagnostic and Support (RADS) program.

BACKGROUND: The diagnostic phase of care is an anxiety-provoking and stressful experience for the potential breast cancer patient. A multidisciplinary team of breast cancer specialists embarked on a new initiative to pilot a Rapid Diagnosis and Support (RADS) Clinic to coordinate the diagnostic workup and nursing support for patients with a high probability of breast cancer. METHODS: Consecutive patients with an initial diagnostic imaging classified as BI-RADS 5 were invited to participate in this 1-year prospective study. Coordination of diagnostic imaging workup and nursing support were provided by a nurse navigator. Wait times were evaluated at several intervals of care. Satisfaction surveys were given to study participants and compared to scores from patients who did not go through RADS clinic. RESULTS: A total of 211 patients participated in the RADS clinic. Biopsy wait times improved from a mean of 7 to 3 days (p < 0.001), pathology from 3.9 to 3.3 days (p < 0.001), surgical consultation from 16.1 to 5.9 days (p < 0.001), and operative wait times from 31.5 to 24.1 days (p = 0.042). There was a 95.3 % satisfaction rate with the RADS clinic with significantly improvement in patients' sense of an understanding of the treatment plan (p = 0.031), timeliness of tests (p = 0.045), and timeliness of results (p = 0.0419). CONCLUSIONS: The RADS clinic significantly improved diagnostic wait times and satisfaction scores for patients with a high probability of diagnosis of breast cancer and can serve as an innovative service delivery model for other breast care centers.

Communication: the key to improving the prostate cancer patient experience.

In 2010, an estimated 24,600 Canadian men were diagnosed with prostate cancer (Canadian Cancer Society, 2011). Upon diagnosis, men and their family members begin an arduous journey of information gathering surrounding prostate cancer and its various forms of treatment. Men have to consider the impact a treatment may potentially have on their quality of life and, frequently, they experience decisional conflict and require support. In May 2008, the Prostate Cancer Assessment Clinic opened to receive men for an evaluation of a possible prostate cancer. Our inter-professional model of care provides support, guidance and education to our patients from assessment to diagnosis and treatment planning. A major goal of our diagnostic assessment unit has been to improve the patient experience. Communication is defined as "to make known, to exchange information or opinions" (Cayne, Lechner, et al., 1988). Nursing is the critical link for information exchange that is patient-centred and collaborative. The focus of this paper will highlight the development and implementation of nurse-led initiatives within our program to improve the prostate cancer patient experience. These initiatives include: a patient information guide, prostate biopsy care, patient resources, community links, surgery education classes and implementation of a decision aid. Communication is the key.