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JCO Oncol Pract ; : OP2200130, 2022 Aug 05.
Article in English | MEDLINE | ID: covidwho-1987096


The Choosing Wisely (CW) campaign, launched in 2012, includes oncology-specific recommendations to promote evidence-based care and deimplementation of low-value practices. However, it is unclear to what extent the campaign has prompted practice change. We systematically reviewed the literature to evaluate the uptake of cancer-specific CW recommendations focusing on the period before the declaration of the COVID-19 pandemic. We used Grimshaw's deimplementation framework to thematically group the findings and extracted information on implementation strategies, barriers, and facilitators from articles reporting on active implementation. In the 98 articles addressing 32 unique recommendations, most reported on passive changes in adherence pre-post publication of CW recommendations. Use of active surveillance for low-risk prostate cancer and reduction in staging imaging for early breast cancer were the most commonly evaluated recommendations. Most articles assessing passive changes in adherence pre-post CW publication reported improvement. All articles evaluating active implementation (10 of 98) reported improved compliance (range: 3%-73% improvement). Most common implementation strategies included provider education and/or stakeholder engagement. Preconceived views and reluctance to adopt new practices were common barriers; common facilitators included the use of technology and provider education to increase provider buy-in. Given the limited uptake of oncology-specific CW recommendations thus far, more attention toward supporting active implementation is needed. Effective adoption of CW likely requires a multipronged approach that includes building stakeholder buy-in through engagement and education, using technology-enabled forced functions to facilitate change along with policy and reimbursement models that disincentivize low-value care. Professional societies have a role to play in supporting this next phase of CW.

BMJ ; 375: e066588, 2021 12 08.
Article in English | MEDLINE | ID: covidwho-1560914


OBJECTIVE: To evaluate the effectiveness of remote proactive management of toxicities during chemotherapy for early stage breast cancer. DESIGN: Pragmatic, cluster randomised trial. SETTING: 20 cancer centres in Ontario, Canada, allocated by covariate constrained randomisation to remote management of toxicities or routine care. PARTICIPANTS: All patients starting adjuvant or neoadjuvant chemotherapy for early stage breast cancer at each centre. 25 patients from each centre completed patient reported outcome questionnaires. INTERVENTIONS: Proactive, standardised, nurse led telephone management of common toxicities at two time points after each chemotherapy cycle. MAIN OUTCOME MEASURES: The primary outcome, cluster level mean number of visits to the emergency department or admissions to hospital per patient during the whole course of chemotherapy treatment, was evaluated with routinely available administrative healthcare data. Secondary patient reported outcomes included toxicity, self-efficacy, and quality of life. RESULTS: Baseline characteristics of participants were similar in the intervention (n=944) and control arms (n=1214); 22% were older than 65 years. Penetration (that is, the percentage of patients who received the intervention at each centre) was 50-86%. Mean number of visits to the emergency department or admissions to hospital per patient was 0.91 (standard deviation 0.28) in the intervention arm and 0.94 (0.40) in the control arm (P=0.94); 47% (1014 of 2158 patients) had at least one visit to the emergency department or a hospital admission during chemotherapy. Among 580 participants who completed the patient reported outcome questionnaires, at least one grade 3 toxicity was reported by 48% (134 of 278 patients) in the intervention arm and by 58% (163 of 283) in the control arm. No differences in self-efficacy, anxiety, or depression were found. Compared with baseline, the functional assessment of cancer therapy trial outcome index decreased by 6.1 and 9.0 points in the intervention and control participants, respectively. CONCLUSIONS: Proactive, telephone based management of toxicities during chemotherapy did not result in fewer visits to the emergency department or hospital admissions. With the rapid rise in remote care because of the covid-19 pandemic, identifying scalable strategies for remote management of patients during cancer treatment is particularly relevant. TRIAL REGISTRATION: NCT02485678.

Antineoplastic Combined Chemotherapy Protocols/administration & dosage , Breast Neoplasms/drug therapy , Monitoring, Ambulatory/methods , Outpatients , Telemedicine , Telephone , Adult , Aged , Aged, 80 and over , Antineoplastic Combined Chemotherapy Protocols/adverse effects , Breast Neoplasms/psychology , COVID-19 , Chemotherapy, Adjuvant/adverse effects , Drug-Related Side Effects and Adverse Reactions , Emergency Service, Hospital/statistics & numerical data , Female , Humans , Middle Aged , Ontario , Pandemics , Quality of Life , SARS-CoV-2 , Surveys and Questionnaires , Treatment Outcome
Int J Qual Health Care ; 33(2)2021 Jun 23.
Article in English | MEDLINE | ID: covidwho-1249305


BACKGROUND: The disruption of health services due to coronavirus disease (COVID) is expected to dramatically alter cancer care; however, the implications for care quality and outcomes remain poorly understood. OBJECTIVE: We undertook a scoping review to evaluate what is known in the literature about how cancer treatment has been modified as a result of the COVID pandemic in patients receiving treatment for solid tumours, and what domains of quality of care are most impacted. METHODS: Citations were retrieved from MEDLINE and EMBASE (from 1 January 2019 to 28 October 2020), utilizing search terms grouped by the key concept (oncology, treatment, treatment modifications and COVID). Articles were excluded if they dealt exclusively with management of COVID-positive patients, modifications to cancer screening, diagnosis or supportive care or were not in English. Articles reporting on guidelines, consensus statements, recommendations, literature reviews, simulations or predictive models, or opinions in the absence of accompanying information on experience with treatment modifications in practice were excluded. Treatment modifications derived from the literature were stratified by modality (surgery, systemic therapy (ST) and radiotherapy) and thematically grouped. To understand what areas of quality were most impacted, modifications were mapped against the Institute of Medicine's quality domains. Where reported, barriers and facilitators were abstracted and thematically grouped to understand drivers of treatment modifications. Findings were synthesized into a logic model to conceptualize the inter-relationships between different modifications, as well as their downstream impacts on outcomes. RESULTS: In the 87 retained articles, reductions in outpatients visits (26.4%) and delays/deferrals were commonly reported across all treatment modalities (surgery: 50%; ST: 55.8% and radiotherapy: 56.7%), as were reductions in surgical capacity (57.1%), alternate systemic regimens with longer treatment intervals or use of oral agents (19.2%) and the use of hypofractionated radiotherapy regimens (40.0%). Delivery of effective, timely and equitable care was the quality domains found to be the most impacted. The most commonly reported facilitator of maintaining cancer care delivery levels was the shift to virtual models of care (62.1%), while patient-initiated deferrals and cancellations (34.8%), often due to fear of contracting COVID (60.9%), was a commonly reported barrier. CONCLUSIONS: As it will take a considerable amount of time for the cancer system to resume capacity and adjust models of care in response to the pandemic, these treatment delays and modifications will likely be prolonged and will negatively impact the quality of care and patient outcomes.

COVID-19 , Neoplasms , Delivery of Health Care , Humans , Models, Theoretical , Neoplasms/therapy , Pandemics , SARS-CoV-2 , United States