Carla Parry

Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transitions Intervention

Objectives: To test whether an intervention designed to encourage older patients and their caregivers to assert a more active role during care transitions can reduce rehospitalization rates.

Cancer Survivors: A Booming Population

Background: In this first article of what is planned to be an annual series, we examine the history of cancer prevalence reporting and the role that these annual figures play in guiding the direction of cancer control research, and specifically the science of cancer survivorship. For this inaugural year, we focus on the confluence of the growing number of survivors and population aging, and the impact these combined trends will have on cancer survivorship in the future. Methods: State or metro area-level cancer incidence and prevalence data were collected from 9 registries via the Surveillance, Epidemiology, and End Results Program. The complete prevalence method was used to estimate prevalence for 2008 and the Prevalence, Incidence Approach Model method was used to project prevalence data through 2020, assuming flat cancer incidence and survival trends but dynamic U.S. population projections. Results: As of January 2008, the number of cancer survivors is estimated at 11.9 million. Approximately 60% of cancer survivors are age 65 or older, and by the year 2020, it is estimated that 63% of cancer survivors will be age 65 or older. Conclusions: Improved survival and population aging converge to generate a booming population of older adult cancer survivors, many of whom have multiple complex health conditions and unique survivorship needs. This demographic shift has important implications for future health care needs and costs of the U.S. population. Impact: The findings provide information critical for guiding cancer prevention and control research and service provision. Cancer Epidemiol Biomarkers Prev; 20(10); 1996–2005. ©2011 AACR.

Assessing the quality of preparation for posthospital care from the patient's perspective: the care transitions measure.

Background:Evidence that both quality and patient safety are jeopardized for patients undergoing transitions across care settings continues to expand. Performance measurement is one potential strategy towards improving the quality of transitional care. A valid and reliable self-report measure of the quality of care transitions is needed that is both consistent with the concept of patient-centeredness and useful for the purpose of performance measurement and quality improvement. Objective:We sought to develop and test a self-report measure of the quality of care transitions that captures the patients perspective and has demonstrated utility for quality improvement. Subjects:Patients aged 18 years and older discharged from one of the 3 hospitals of a vertically integrated health system were included. Research Design:Cross-sectional assessment of factor structure, dimensionality, and construct validity. Results:The Care Transitions Measure (CTM), a 15-item uni-dimensional measure of the quality of preparation for care transitions, was found to have high internal consistency, reliability, and reflect 4 focus group-derived content domains. The measure was shown to discriminate between patients discharged from the hospital who did and did not have a subsequent emergency department visit or rehospitalization for their index condition. CTM scores were significantly different between health care facilities known to vary in level of system integration. Conclusions:The CTM not only provides meaningful, patient-centered insight into the quality of care transitions, but because of the association between CTM scores and undesirable utilization outcomes, it also provides information that may be useful to clinicians, hospital administrators, quality improvement entities, and third party payers.

Working without a net: Leukemia and lymphoma survivors' perspectives on care delivery at end-of-treatment and beyond

This study explored survivors’ perspectives on care delivery and supportive care needs during reentry. Fifty-one individual interviews were conducted with adult leukemia and lymphoma survivors, 3 to 48 months from treatment cessation. Survivors reported poor continuity of care across the patient–survivor transition, difficulty finding appropriate information/services, lack of preparation, lack of support for survivorship issues, and inadequate or poorly timed follow-up as factors contributing to adjustment difficulties at end of treatment and beyond. Improved care coordination is needed after active treatment, including use of an exit interview and delivery of services that are more congruent and better timed to meet ongoing and emergent survivorship needs.

Further Application of the Care Transitions Intervention: Results of a Randomized Controlled Trial Conducted in a Fee-For-Service Setting

The study objective was to test whether a self-care model for transitional care that has been demonstrated to improve outcomes in Medicare Advantage populations—The Care Transitions Intervention—could also improve outcomes in a Medicare fee-for-service population. Intervention patients were less likely to be readmitted to a hospital in general and for the same condition that prompted their index hospitalization at 30, 90, and 180 days versus control patients. Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rate of subsequent rehospitalization in a Medicare fee-for-service population.

Assessing the Quality of Transitional Care Further Applications of the Care Transitions Measure

Background:The Institute of Medicine has identified care transitions as a priority area for performance measurement. Objectives:To examine the performance of the Care Transitions Measure (CTM) in more diverse populations and to introduce a 3-item CTM. Research Design:Cross-sectional study with purposive sampling of traditionally underserved populations. Confirmatory factor analyses, internal consistency reliability analyses, and differential item function tests were performed to explore the stability and performance of the 15-item CTM. Regression assessed the ability of the 3-item CTM to predict the 15-item CTM total score. Analysis of variance tests were conducted to explore CTM performance in different populations with respect to health and demographics. Subjects:A total of 225 patients age 18–90 who were hospitalized in the past 12 months and were African American, Hispanic American, or rural-dwelling. Measures:CTM-15, CTM-3, age, gender, education, and health status. Results:Mplus confirmatory factor analysis supported the CTM-15 factor structure in more diverse population (Comparative Fit Index [CFI] = 0.954). The 3-item CTM explained 88% of the variance in the 15-item CTM score. Differential item function analysis did not reveal any differential item difficulty by age, gender, education, self-rated health, or group (African American, Hispanic American, and rural-dwelling). Conclusions:Following endorsement by National Quality Forum, findings support use of the CTM in national public reporting efforts. The 3-item CTM closely approximates the 15-item instrument and may be attractive to purchasers and health care organizations that want to assess quality in this area while minimizing cost and response burden.

Can't see the forest for the care plan: a call to revisit the context of care planning.

In its 2006 report “From Cancer Patient to Cancer Survivor: Lost in Transition,”1 the Institute of Medicine (IOM) provided suggestions for improving transitional and follow-up care for the growing population of cancer survivors. The IOM recommended that all patients completing primary treatment for cancer be provided with a comprehensive treatment summary and follow-up care plan, together referred to as a survivorship care plan (SCP).1,2 The IOM recommended that the SCP be reviewed with the patient during an end-of-treatment consultation, in the hope that use of an SCP and consultation would foster improved care coordination and communication.1 The IOM panel acknowledged the lack of an evidence base for survivorship care planning but concluded that “some elements of care simply make sense—that is, they have strong face validity and can reasonably be assumed to improve care unless and until evidence accumulates to the contrary.”1p5 However, the IOM report went on to call for health services research to assess the impact, cost, and acceptability of SCPs with regard to patients and providers.1

Perceived Positive Impact of Cancer Among Long-term Survivors of Childhood Cancer: a report from the Childhood Cancer Survivor Study

Investigations examining psychosocial adjustment among childhood cancer survivors have focused primarily on negative effects and psychopathology. Emergent literature suggests the existence of positive impact or adjustment experienced after cancer, as well. The purpose of this study is to examine the distribution of Perceived Positive Impact (PPI) and its correlates in young adult survivors of childhood cancer.

Use of Survivorship Care Plans in the United States: Associations With Survivorship Care

BACKGROUND Survivorship care plans (SCPs), including a treatment summary and follow-up plan, intend to promote coordination of posttreatment cancer care; yet, little is known about the provision of these documents by oncologists to primary care physicians (PCPs). This study compared self-reported oncologist provision and PCP receipt of treatment summaries and follow-up plans, characterized oncologists who reported consistent provision of these documents to PCPs, and examined associations between PCP receipt of these documents and survivorship care. METHODS A nationally representative sample of medical oncologists (n = 1130) and PCPs (n = 1020) were surveyed regarding follow-up care for breast and colon cancer survivors. All statistical tests were two-sided. Multivariable regression models identified factors associated with oncologist provision of treatment summaries and SCPs to PCPs (always/almost always vs less frequent). RESULTS Nearly half of oncologists reported always/almost always providing treatment summaries, whereas 20.2% reported always/almost always providing SCPs (treatment summary + follow-up plan). Approximately one-third of PCPs indicated always/almost always receiving treatment summaries; 13.4% reported always/almost always receiving SCPs. Oncologists who reported training in late- and long-term effects of cancer and use of electronic medical records were more likely to report SCP provision (P < .05). PCP receipt of SCPs was associated with better PCP-reported care coordination, physician-physician communication, and confidence in survivorship care knowledge compared to receipt of neither treatment summaries nor SCPs (P < .05). CONCLUSIONS Providing SCPs to PCPs may enhance survivorship care coordination, physician-physician communication, and PCP confidence. However, considerable progress will be necessary to achieve implementation of sharing SCPs among oncologists and PCPs.

“You’re too young for this”: Adolescent and Young Adults’ Perspectives on Cancer Survivorship

Adolescent and young adult cancer survivors face unique challenges not systematically addressed by cancer clinicians. Four focus groups and two individual interviews were conducted with 19 survivors to profile experiences and identify key concerns for future interventions. The resultant themes reflect cancer care continuum challenges (such as delays in diagnosis, problems with adherence), psychosocial concerns (such as infertility and reproductive concerns, changing social relationships, financial burden), and the paradox of being diagnosed with cancer as a young adult. Future intervention development for adolescent and young adult survivors should involve patient voices at each stage of the research process.