Robin Morash

Piloting a regional collaborative in cancer surgery using a “community of practice” model

BACKGROUNDnPatients requiring assessment for cancer surgery encounter a complex series of steps in their cancer journey. Further complicating the process is the fact that care is often delivered in a fragmented, silo-based system. Isolated strategies to improve cancer outcomes within those systems have had inconsistent results.nnnMETHODSnA regional quality improvement collaborative was developed based on a community of practice (cop) platform, a hub-and-spoke infrastructure, and a regional steering committee linking cop improvement projects with affiliated hospitals and their strategic priorities. The cop provided an avenue for multidisciplinary teams to collect and compare their performance data and to institute regional standards through literature review, discussion, and consensus. Regional interdisciplinary teams developed a set of quality indicators linked to mutually agreed-upon care standards. A limited regional database supported feedback about performance against both provincial and regional standards.nnnRESULTSnThe cop approach helped to develop a multihospital collaboration that facilitated care quality improvements on a regional scale, with clinical outcomes of the improvements able to be measured. The 9 participating hospitals delivered cancer surgery in the specific disease sites according to practitioner-developed and provincially- or regionally-generated care standards and clinical pathways. Compliance with provincial evidence-based clinical guidelines improved (20% increase in 2010-2011 compared with 2006-2007). Other significant improvements included standardization and implementation of regional perioperative pathways in breast, colorectal, and prostate cancer disease sites; rectal cancer surgery centralization; increased use of sentinel lymph node biopsies in breast cancer surgery; and decreased positive surgical margin rates in prostate cancer.nnnCONCLUSIONSnImproved quality is likely a result of diverse confounding factors. The deliberately cultivated multihospital multidisciplinary cops have contributed to positive structural and functional change in cancer surgery in the region. This regional cop model has the potential to play an important role in the development of successful collaborations in care quality improvement.

Exploring a "community of practice" methodology as a regional platform for large-scale collaboration in cancer surgery-the Ottawa approach.

Pressing challenges have forced health care providers to rethink traditional silos and professional boundaries. Communities of practice (cops) have been identified as a means to share knowledge across silos and boundaries. However, clarity sufficient to enable their easy and uniform reproducibility is lacking, leading to a gap between cop conceptualization and implementation. This paper explores a cop structure and outlines a framework that is adaptable, measurable, and implementable across health disciplines in a regional cancer surgery program.

Wellness Beyond Cancer Program: building an effective survivorship program

BACKGROUNDnThe Wellness Beyond Cancer Program (wbcp) was launched in 2012, first accepting patients with colorectal cancer (crc) and, subsequently, those with breast cancer (bca), with the aim of standardizing and streamlining the discharge process from our cancer centre. Patients are discharged either to the wbcp nurse practitioner or to their primary care provider (pcp). The program incorporates survivorship care plans (scps) and education classes; it also has a rapid re-entry system in case of recurrence. The objective of this paper is to describe the process by which a cancer survivorship program was developed at our institution and to present preliminary evaluation results.nnnMETHODSnQualitative surveys were mailed to patients and pcps 1 year after patients had been referred to the wbcp. The surveys addressed knowledge of the program content, satisfaction on the part of patients and providers, and whether scp recommendations were followed. Questions were scored on the level of agreement with each of a list of statements (1 = strongly disagree to 5 = strongly agree).nnnRESULTSnFrom March 2012 to November 2014, 2630 patients were referred to the wbcp (809 with crc, 1821 with bca). Surveys were received from 289 patients and 412 pcps. Patients and pcps gave similar scores (average: 4) to statements about satisfaction; pcps gave scores below 4 to statements about communication with the wbcp.nnnCONCLUSIONSnAt 1 year after discharge, patients and pcps were satisfied with program content, but there is an opportunity to improve on communication and provision of cancer-specific information to the pcps. Using the wbcp to ensure a safe transition to the most appropriate health care provider, we have standardized the discharge process for crc and bca patients.

Use of a community of practice (CoP) platform as a model in regional quality improvements in cancer surgery: The Ottawa model.

68 Background: The Ottawa CoP model for developing multidisciplinary practitioner networks and integrating them with organizational processes was established in 2007 as a platform improving access to quality cancer surgery in one of the health regions (population 1,276,370) of Ontario, Canada. The three inter-disciplinary CoP collaboratives in breast, colorectal, and prostate cancer involve 230 care providers from 9 hospitals performing over 2,000 cancer surgeries per year.nnnOBJECTIVESn1) to address lack of coordination and standardization of care, 2) develop a regional platform for quality initiatives, and 3) bridge the gap between academic and community hospitals.nnnMETHODSnUsing the model, an academic tertiary care hospital and eight community hospitals partnered to support a regional quality improvement initiative that combines 1) educational outreach with audit and feedback to address variations in practice and 2) a unique platform for knowledge generation and innovation. Regional interdisciplinary teams developed a set of regional quality indicators (18) linked to mutually agreed standards and pathways. Regional registry was established to provide data feedback on performance against both provincial and regional standards. Best practices, innovations, and implementation progress are reviewed through sustained interactions between CoP members. Patient and care provider surveys are conducted.nnnRESULTSnThe development and implementation of regional care standards and clinical pathways for three disease sites in 9 hospitals. Regional pathway compliance ranged 65-94%. Other significant improvements include: rectal cancer surgery centralization (80-90% per annum), increase in use of sentinel lymph node biopsies in breast cancer surgery (60-77% per annum) and a decreased positive prostate cancer surgical margin rate form 45% to 22%. Compliance with provincial guidelines for colon cancer surgery improved (20% increase 2006/2007 vs. 2010/2011). Increase in patient access to high-quality cancer surgery closer to home.nnnCONCLUSIONSnParticipation in the regional CoPs is associated with quality improvements at the system, patient, and professional levels.

Empowering cancer survivors to meet their physical and psychosocial needs: An implementation evaluation

Our Wellness Beyond Cancer Survivorship Program was established and evaluated as a quality improvement project. Individualized survivorship care plans for survivors and primary care providers included cancer surveillance recommendations and survivors self-reported physical and psychosocial needs. At the discharge visit, an oncology nurse reviewed the care plan and symptom management strategies with survivors. We assessed the physical and psychosocial needs and feelings of empowerment of 70 breast and 53 colorectal cancer survivors on entry into the program and one year after discharge to primary care. Survivors were months to 10 or more years since the end of active treatment, with colorectal cancer survivors referred sooner (average 1.2 years). At baseline, colorectal cancer survivors reported little concern about their needs (scores <1.0 out of 5.0) and breast cancer survivors reported some concern about sleep disturbances, weight changes, memory/concentration changes, and fear of recurrence (scores 1.0 to 1.5 out of 5.0). All survivors reported feeling empowered (>3.0 out of 4.0). Needs and empowerment levels were mostly unchanged one year later. Colorectal cancer survivors showed a statistically significantly increased fear of recurrence at one year. In summary, cancer survivors with a survivorship care plan continued to feel empowered one year following discharge.

Autonomisation des survivants du cancer pour répondre à leurs besoins physiques et psychosociaux : évaluation d’un projet

Notre Programme de bien-etre au-dela du cancer a ete etabli et evalue en tant que projet d’amelioration de la qualite. Les plans de soins individualises pour les survivants et les fournisseurs de soins primaires incluaient des recommandations sur la surveillance du cancer et sur les besoins physiques et psychosociaux signales par les survivants. Au rendez-vous de transition, une infirmiere en oncologie a passe en revue le plan de soins et les strategies de gestion des symptomes avec les survivants. Nous avons evalue les besoins physiques et psychosociaux, et le sentiment d’autonomie de 70xa0survivantes du cancer du sein et de 53xa0survivants du cancer colorectal a l’adhesion au programme, puis une annee apres la transition aux soins primaires. Les survivants ne recevaient plus de traitement actif depuis des mois, voire des annees (10xa0ans et plus), mais les survivants du cancer colorectal ont ete aiguilles plus tot (1,2xa0an en moyenne). Au depart, on a observe que les survivants du cancer colorectal s’inquietaient peu de leurs besoins (scores xa03,0 sur 4,0). Les besoins et les niveaux d’autonomisation etaient pour la plupart les memes apres une annee. On observe statistiquement que les survivants du cancer colorectal avaient davantage peur de la recidive apres un an. En resume, les survivants du cancer dotes d’un plan de soins continuent de se sentir autonomises un an apres avoir recu leur conge.

Reducing overtreatment of prostate cancer by radical prostatectomy in Eastern Ontario: a population-based cohort study

BACKGROUNDnCanadian guidelines recommend against population-based screening for prostate cancer because of the risk of overdiagnosis and overtreatment. We sought to assess whether a higher proportion of patients receiving surgery had clinically significant cancer over time.nnnMETHODSnAll hospitals in Eastern Ontario that perform prostatectomy participate in a Prostate Cancer Community of Practice, which prospectively maintains a database for the region. Using these data, we conducted a retrospective cohort study that included all patients who underwent prostatectomy from 2009 to 2015 in the region. We examined trends in biopsy findings, clinical stage, prostate-specific antigen level and Gleason score. We then determined whether the proportion of patients with clinically significant cancer (Gleason score ≥ 7 or stage pT3) increased over time.nnnRESULTSnDuring the study period, 1897 patients underwent prostatectomy in Eastern Ontario (mean 271 surgeries/yr). The proportion of patients who were determined to have National Comprehensive Cancer Network intermediate or high-risk disease increased from 46.7% in 2009 to 90.2% in 2015. The proportion of men with clinically significant cancer on prostatectomy increased from 59.7% in 2009 to 93.1% in 2015. Adjusted analyses suggested that the proportion of patients with clinically significant cancer increased by 5% per year during the study period.nnnINTERPRETATIONnThere has been a change in the tumour characteristics of patients who undergo prostatectomy in Eastern Ontario. In recent years, almost all patients have had clinically significant cancer, which suggests that overtreatment of prostate cancer has decreased.

Évaluation de la mise en œuvre d’une séance d’information à l’intention des survivantes dans le cadre d’un Programme de bien-être au-delà du cancer : portrait des participantes

Les survivantes du cancer du sein et de l’endometre orientees vers le Programme de bien-etre au-dela du cancer ont ete invitees a participer a une seance d’information, mais elles n’ont pas toutes donne suite a cette invitation. La presente etude cherche donc a determiner les caracteristiques sociodemographiques et medicales, ainsi que les besoins des survivantes, qui permettraient de predirexa0 leur participation a ce type d’atelier. Pour ce faire, un examen du dossier des survivantes ayant rempli une enquete d’evaluation des besoins entre 2012 et 2014 (n = 144, cancer de l’endometre; n = 170, cancer du sein) a ete realise. Les caracteristiques des participantes ont ete comparees a celles des femmes qui n’etaient pas presentes a l’aide de tests t, d’analyses du khi-carre et d’une analyse de regres- sion. Les analyses univariees ont montre une correlation entre la participation a la seance d’information et l’age, la proximite de l’hopital, les besoins emotionnels et physiques, et les traitements de chimiotherapie ou de radiotherapie qui avaient ete recus. La proxi- mite de l’hopital et les besoins physiques sont quant a eux ressortis comme des facteurs predictifs multivaries. Les resultats de l’etude nous permettront d’etoffer le contenu de la seance d’information, d’accroitre le taux de participation et de cerner les caracteristiques des participantes.

An Implementation Evaluation of the Wellness Beyond Cancer Survivorship Class: Who is attending?

Breast and endometrial cancer survivors referred to the Wellness Beyond Cancer Program were invited to a survivorship education class. As not all survivors attended the class, this study aimed to identify socio-demographic and medical characteristics, and survivorship needs that predict attendance. A chart review was conducted on survivors who completed a needs assessment survey between 2012 and 2014 (n=144 endometrial; n=170 breast). Class attendees characteristics were compared to those of non-attendees using t-tests, chi-square analyses, and regression analysis. Univariate analyses showed that age, distance from hospital, emotional and physical needs, and receiving chemotherapy and/or radiation therapy were associated with class attendance. Distance from hospital and physical needs were identified as multivariate predictors. The results of this study will help inform class content, improve class attendance, and identify attendees characteristics.

Abstract P1-09-29: A new model of care for breast cancer survivorship

Background Breast cancer (BC) is the most common cancer diagnosed in women. With advances in diagnostics and therapy, early stage disease has an estimated 85% 10-year overall survival. Cancer survivors have unique needs including screening for recurrence, psychosocial concerns, as well as routine health maintenance. There is growing evidence to support the safe transition from oncologist to primary care. This is challenging in the era of complex adjuvant and extended adjuvant programs, which are standard of care for women with hormone receptor positive BC. In February 2013 the Wellness Beyond Cancer Program (WBCP), developed at the Ottawa Regional Cancer Program, started accepting BC patients. A risk stratification system enables the treating oncologist to determine the most appropriate care provider stream based on patient complexity and/or risk of relapse. There are three possible streams: primary care provider (PCP), nurse practitioner (NP), or oncologist. The program offers education on general and breast specific cancer survivorship issues. Unique to our program is a hormone re-assessment review (HRR), scheduled in advance, to discuss switching hormonal therapies and/or extended adjuvant strategies. A rapid re-entry system is in place for those with evidence of disease recurrence or a new primary. Specific aims The aims of our study are: 1. To describe unique aspects of WBCP developed for early stage BC patients 2. To assess efficacy of the WBCP 3. To evaluate safety of the HRR 4. To examine patient and primary care giver satisfaction with the program Methods All BC patients eligible for discharge through the WBCP will be included in the evaluation. We will evaluate patients by examining needs assessments completed at time of referral and one year later, as well as completed patient and PCP satisfaction surveys. The proportion of patients with changing scores, increasing or decreasing, will reflect improvements or worsening of needs. The proportion of both patients and PCP that are/are not satisfied with the program will be recorded and examined further. For the HRR we will code the proportion of patients where the consult was requested and was scheduled vs. not scheduled. Finally, the number/proportion of patients and reasons for re-entry will be captured. Results February 2013–June 2014, 1339 BC patients were referred to the program, 584 patients to PCP, 740 to NP, and 15 remaining with their oncologist. Early results are reported here with results of the surveys expected by December 2014. 7 patients have required re-entry for disease recurrence and 30 HRR have been booked. No cancer specific negative outcomes have been reported. Survey results addressing patient needs, empowerment and concerns are being collated, with PCP satisfaction results to be reported. Conclusion Our institution has endorsed evidence-based recommendations for an organized survivorship program and has taken it a step further by developing a strategy to address the unique long term needs of hormone positive early stage breast cancer. Early feedback supports that this program has increased patient and caregiver knowledge of survivorship issues and anticipates improved patient empowerment, without compromising cancer specific outcomes. Citation Format: Moira Rushton, Robin Morash, Gail Larocque, Carrie Liska, Roanne Segal. A new model of care for breast cancer survivorship [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-09-29.