Irene Prabhu Das

The Organization of Multidisciplinary Care Teams: Modeling Internal and External Influences on Cancer Care Quality

Quality cancer treatment depends upon careful coordination between multiple treatments and treatment providers, the exchange of technical information, and regular communication between all providers and physician disciplines involved in treatment. This article will examine a particular type of organizational structure purported to regularize and streamline the communication between multiple specialists and support services involved in cancer treatment: the multidisciplinary treatment care (MDC) team. We present a targeted review of what is known about various types of MDC team structures and their impact on the quality of treatment care, and we outline a conceptual model of the connections between team context, structure, process, and performance and their subsequent effects on cancer treatment care processes and patient outcomes. Finally, we will discuss future research directions to understand how MDC teams improve patient outcomes and how characteristics of team structure, culture, leadership, and context (organizational setting and local environment) contribute to optimal multidisciplinary cancer care.

Introduction: Understanding and Influencing Multilevel Factors Across the Cancer Care Continuum

Health care in the United States is notoriously expensive while often failing to deliver the care recommended in published guidelines. There is, therefore, a need to consider our approach to health-care delivery. Cancer care is a good example for consideration because it spans the continuum of health-care issues from primary prevention through long-term survival and end-of-life care. In this monograph, we emphasize that health-care delivery occurs in a multilevel system that includes organizations, teams, and individuals. To achieve health-care delivery consistent with the Institute of Medicines six quality aims (safety, effectiveness, timeliness, efficiency, patient-centeredness, and equity), we must influence multiple levels of that multilevel system. The notion that multiple levels of contextual influence affect behaviors through interdependent interactions is a well-established ecological view. This view has been used to analyze health-care delivery and health disparities. However, experience considering multilevel interventions in health care is much less robust. This monograph includes 13 chapters relevant to expanding the foundation of research for multilevel interventions in health-care delivery. Subjects include clinical cases of multilevel thinking in health-care delivery, the state of knowledge regarding multilevel interventions, study design and measurement considerations, methods for combining interventions, time as a consideration in the evaluation of effects, measurement of effects, simulations, application of multilevel thinking to health-care systems and disparities, and implementation of the Affordable Care Act of 2010. Our goal is to outline an agenda to proceed with multilevel intervention research, not because it guarantees improvement in our current approach to health care, but because ignoring the complexity of the multilevel environment in which care occurs has not achieved the desired improvements in care quality outlined by the Institute of Medicine at the turn of the millennium.

Multilevel Interventions and Racial/Ethnic Health Disparities

To examine the impact of multilevel interventions (with three or more levels of influence) designed to reduce health disparities, we conducted a systematic review and meta-analysis of interventions for ethnic/racial minorities (all except non-Hispanic whites) that were published between January 2000 and July 2011. The primary aims were to synthesize the findings of studies evaluating multilevel interventions (three or more levels of influence) targeted at ethnic and racial minorities to reduce disparities in their health care and obtain a quantitative estimate of the effect of multilevel interventions on health outcomes among these subgroups. The electronic database PubMed was searched using Medical Subject Heading terms and key words. After initial review of abstracts, 26 published studies were systematically reviewed by at least two independent coders. Those with sufficient data (n = 12) were assessed by meta-analysis and examined for quality using a modified nine-item Physiotherapy Evidence Database coding scheme. The findings from this descriptive review suggest that multilevel interventions have positive effects on several health behavior outcomes, including cancer prevention and screening, as well improving the quality of health-care system processes. The weighted average effect size across studies for all health behavior outcomes reported at the individual participant level (k = 17) was odds ratio (OR) = 1.27 (95% confidence interval [CI] = 1.11 to 1.44); for the outcomes reported by providers or organizations, the weighted average effect size (k = 3) was OR = 2.53 (95% CI = 0.82 to 7.81). Enhanced application of theories to multiple levels of change, novel design approaches, and use of cultural leveraging in intervention design and implementation are proposed for this nascent field.

Assessing the Development of Multidisciplinary Care: Experience of the National Cancer Institute Community Cancer Centers Program

PURPOSE The National Cancer Institute Community Cancer Centers Program (NCCCP) began in 2007 with a goal of expanding cancer research and delivering quality care in communities. The NCCCP Quality of Care (QoC) Subcommittee was charged with developing and improving the quality of multidisciplinary care. An assessment tool with nine key elements relevant to MDC structure and operations was developed. METHODS Fourteen NCCCP sites reported multidisciplinary care assessments for lung, breast, and colorectal cancer in June 2010, June 2011, and June 2012 using an online reporting tool. Each site evaluated their level of maturity (level 1 = no multidisciplinary care, level 5 = highly integrated multidisciplinary care) in nine elements integral to multidisciplinary care. Thematic analysis of open-ended qualitative responses was also conducted. RESULTS The proportion of sites that reported level 3 or greater on the assessment tool was tabulated at each time point. For all tumor types, sites that reached this level increased in six elements: case planning, clinical trials, integration of care coordination, physician engagement, quality improvement, and treatment team integration. Factors that enabled improvement included increasing organizational support, ensuring appropriate physician participation, increasing patient navigation, increasing participation in national quality initiatives, targeting genetics referrals, engaging primary care providers, and integrating clinical trial staff. CONCLUSIONS Maturation of multidisciplinary care reflected focused work of the NCCCP QoC Subcommittee. Working group efforts in patient navigation, genetics, and physician conditions of participation were evident in improved multidisciplinary care performance for three common malignancies. This work provides a blueprint for health systems that wish to incorporate prospective multidisciplinary care into their cancer programs.

Time Issues in Multilevel Interventions for Cancer Treatment and Prevention

The concept of time introduces important complexities in estimating intervention effects, program and evaluation design, and measurement and analysis of individual change in multilevel interventions (MLIs). Despite growing recognition that time is a critical element for assessing both individual-level outcomes and higher-level changes in organizational, community, and policy contexts, most MLI designs and evaluations have not addressed these issues. In this chapter we discuss 1) conceptualizing disease life-course and treatment theory in MLIs, 2) approaches to incorporating time in research and program design for MLIs in cancer treatment and prevention, 3) analysis of time-varying multilevel data in the context of cancer treatment and prevention, and 4) resource considerations and trade-offs of incorporating time as a dimension of MLIs and analysis. Although analytic techniques for analyzing time-related phenomena are becoming more available and powerful, there has not been corresponding progress made in the development of theory to guide the application of these techniques in program design and implementation.

ReCAP: Impact of Multidisciplinary Care on Processes of Cancer Care: A Multi-Institutional Study

PURPOSE The role of multidisciplinary care (MDC) on cancer care processes is not fully understood. We investigated the impact of MDC on the processes of care at cancer centers within the National Cancer Institute Community Cancer Centers Program (NCCCP). METHODS The study used data from patients diagnosed with stage IIB to III rectal cancer, stage III colon cancer, and stage III non–small-cell lung cancer at 14 NCCCP cancer centers from 2007 to 2012. We used an MDC development assessment tool—with levels ranging from evolving MDC (low) to achieving excellence (high)—to measure the level of MDC implementation in seven MDC areas, such as case planning and physician engagement. Descriptive statistics and cluster-adjusted regression models quantified the association between MDC implementation and processes of care, including time from diagnosis to treatment receipt. RESULTS A total of 1,079 patients were examined. Compared with patients with colon cancer treated at cancer centers reporting low MDC scores, time to treatment receipt was shorter for patients with colon cancer treated at cancer centers reporting high or moderate MDC scores for physician engagement (hazard ratio [HR] for high physician engagement, 2.66; 95% CI, 1.70 to 4.17; HR for moderate physician engagement, 1.50; 95% CI, 1.19 to 1.89) and longer for patients with colon cancer treated at cancer centers reporting high 2MDC scores for case planning (HR, 0.65; 95% CI, 0.49 to 0.85). Results for patients with rectal cancer were qualitatively similar, and there was no statistically significant difference among patients with lung cancer. CONCLUSION MDC implementation level was associated with processes of care, and direction of association varied across MDC assessment areas.

Summary of the multilevel interventions in health care conference.

Patient outcomes are a primary measure by which we assess healthcare delivery quality. Those outcomes are influenced by numerous other factors in the multilevel context of care described in this monograph (1). Factors include policies that enable or impede health-care access, social support from friends and family, processes of health-care teams, organizational procedures in settings where care is delivered, and the environmental context where these behaviors occur. A few years ago, an internal team of researchers at the National Cancer Institute (NCI) within the Division of Cancer Control and Population Sciences recognized the importance of studying the context in which health care is received to intervene on multiple levels of influence. However, the science of multilevel interventions was in an early stage of development. Thus, the NCI researchers (henceforth “the NCI planning team”) reached out to the extramural community to identify expertise that would help advance this science. The collaborations led to a set of draft articles presented at a conference titled Multilevel Interventions in Health Care: Building a Foundation for Future Research (Las Vegas, NV, March 4–5, 2011). Comments from that conference led to the final articles presented in this issue. The purpose of this article is to describe the relationship between the research articles and the conference to provide richer context for this monograph. We include a summary of the conference events to reflect the complementary development of the articles, to promote more open discussion of the issues among researchers, and to acknowledge the contribution of the meeting participants. In addition, this article summarizes the history behind the conference, its structure, the themes that developed there, and efforts that began after the conference to encourage discussion about multilevel interventions.

The National Cancer Institute Community Cancer Centers Program (NCCCP): Sustaining Quality and Reducing Disparities in Guideline‐Concordant Breast and Colon Cancer Care

This study builds on analyses performed as part of an original comprehensive National Cancer Institute Community Cancer Centers Program evaluation and examines improvements in quality of care. The following research questions are addressed: (a) have improvements in concordance rates with the five quality of care measures been sustained since 2010 and (b) how does the change in concordance for minority/underserved patients compare to the change for nonminority/nonunderserved patients through 2013?

Abstract PR13: Availability of Patient Navigation Services at NCI Community Oncology Research Program (NCORP) Community Sites

Purpose: Patient navigation, support and guidance provided by trained culturally sensitive health care workers, has been promoted as a strategy to improve care quality and reduce cancer health disparities. Yet, the availability and extent of navigation in community oncology practices is unclear. The purpose of this analysis was to assess: 1) availability of navigation services across diverse community oncology practices and 2) characteristics of oncology practices that do and do not offer navigation. Methods: Community oncology practices were surveyed regarding availability of cancer navigation services, cancer types served, and presence of lay and nurse navigators, as part of a larger survey of cancer care delivery research (CCDR) capacity of NCI Community Oncology Research Program (NCORP) sites. CCDR leads at practices reported navigation data, along with other information about the site. Results: We collected data from 350 of 401 CCDR-designated NCORP oncology sites, representing 201 adult practices. The majority of the practices included a hospital-based outpatient clinic (73.6%) and were multi-specialty (76.6%). 15.9% were designated by NCORP as minority and underserved community sites and 14.4% self-identified as a safety net hospital. Navigation services were not available to cancer patients at 20.0% of practices; 45.2% of practices provided navigation to all patients and 34.8% provided it to some oncology patients. Larger practices were more likely to provide navigation to some or all patients (vs none); ORs for 5-9, 10-17, and 18+ providers (vs 1-4 providers), respectively, were 6.1, 8.9, and 3.3 (all p Conclusions: Navigation is available in some capacity in a majority of community oncology practices, but variation exists in cancer types covered and integration in the care continuum. Details regarding what specific navigation activities were provided and impact on cancer disparities are not known. Practices designated as serving a larger proportion of minority and underserved patients were more likely to provide navigation to all patients, if they offered it. The widespread availability of navigation in NCORP community sites provides opportunities for observational and intervention studies to assess the impact of navigation on cancer outcomes. Citation Format: Kathryn E. Weaver, Lucy Gansauer, Nicholas M. Pajewski, Kathleen Castro, Ruth Carlos, Irene Prabhu Das, Marvella E. Ford, Ann M. Geiger. Availability of Patient Navigation Services at NCI Community Oncology Research Program (NCORP) Community Sites. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr PR13.

NCI Community Cancer Center Program (NCCCP): Understanding why hormonal therapy for breast cancer was considered but not administered.

74 Background: The National Cancer Institute Community Cancer Centers Program (NCCCP) was designed to improve the quality of cancer care and reduce disparities at hospital-based community cancer centers. This study examined when guideline-concordant therapy was considered but not administered, who made the decision to not receive treatment. METHODS A retrospective analysis of patients diagnosed and receiving all or part of their initial cancer treatment at one of 12 NCCCP sites was conducted. We examined patients who were guideline-concordant with the hormonal therapy (HT) for breast cancer quality measure, but for whom treatment was considered but not administered. We compared patients diagnosed in the pre-NCCCP period (2006 - 2007) and during the NCCCP period (2008-2013). RESULTS Overall, a low proportion of cases had HT considered but not administered (4% in pre-NCCCP period; 5% in NCCCP period - difference not significant). In the pre-NCCCP period, white patients were twice as likely as Black patients to have HT considered but not administered, while there were no racial differences during the NCCCP period. In both time periods, older patients and Medicare patients were more likely to have HT considered but not administered. The most common reason for considering but not administering HT was refusal by the patient or patients family and this more likely for White patients, patients in the middle age groups (50-59 and 60 to 69), and Medicare patients. The second most common reason was that the physician determined it to be contraindicated due to patient risk factors. This was more likely to be a reason for Black and Medicaid patients. CONCLUSIONS Results show that a large proportion of cases that had treatment considered but not administered did not receive treatment because of patient/family refusal or it was contraindicated due to other patient risk factors, both before and during the NCCCP period. Additional studies could inform the long-term outcomes of patients with comorbid conditions who were considered for guideline-concordant treatment but did not receive it (but the data were not available for this study).