"All boats will rise": Physicians' perspectives on multidisciplinary lung cancer care in a community-based hospital setting.

PURPOSE: We explored the perceived strengths, barriers to implementation, and suggestions for sustainable implementation of a multidisciplinary model within a community-based hospital system from the physicians' perspectives. METHODS: We conducted 9 focus groups with 37 physicians involved in the care of lung cancer patients. Grounded theory methodology guided the identification of recurrent themes that emerged from the qualitative data analysis. RESULTS: The majority of study participants agreed that the multidisciplinary model could benefit patients by promoting high quality, efficient, and well-coordinated care. Co-location, financial disincentives, and time constraints were identified as major deterrents to full participation in a multidisciplinary clinic. Other perceived challenges were the integration of a multidisciplinary care model into the existing healthcare system, maintenance of referral streams, and designation of the physician primarily responsible for a patient's care. Educating physicians about the availability of a multidisciplinary clinic, establishing efficient processes for initial consultations, implementing technology for virtual participation, and using a nurse navigator with reliable closed-loop communication were suggested to improve the implementation of the multidisciplinary model. CONCLUSIONS: Physicians generally agreed that the multidisciplinary model could improve lung cancer care, but they perceived significant personal, institutional, and system-level barriers that need to be addressed for its successful implementation in a community healthcare setting.

Pragmatic trial of a multidisciplinary lung cancer care model in a community healthcare setting: study design, implementation evaluation, and baseline clinical results.

BACKGROUND: Responsible for 25% of all US cancer deaths, lung cancer presents complex care-delivery challenges. Adoption of the highly recommended multidisciplinary care model suffers from a dearth of good quality evidence. Leading up to a prospective comparative-effectiveness study of multidisciplinary vs. serial care, we studied the implementation of a rigorously benchmarked multidisciplinary lung cancer clinic. METHODS: We used a mixed-methods approach to conduct a patient-centered, combined implementation and effectiveness study of a multidisciplinary model of lung cancer care. We established a co-located multidisciplinary clinic to study the implementation of this care-delivery model. We identified and engaged key stakeholders from the onset, used their input to develop the program structure, processes, performance benchmarks, and study endpoints (outcome-related process measures, patient- and caregiver-reported outcomes, survival). In this report, we describe the study design, process of implementation, comparative populations, and how they contrast with patients within the local and regional healthcare system. Trial Registration: ClinicalTrials.gov Identifier: NCT02123797. RESULTS: Implementation: the multidisciplinary clinic obtained an overall treatment concordance rate of 90% (target >85%). Satisfaction scores were high, with >95% of patients and caregivers rating themselves as being "very satisfied" with all aspects of care from the multidisciplinary team (patient/caregiver response rate >90%). The Reach of the multidisciplinary clinic included a higher proportion of minority patients, more women, and younger patients than the regional population. Comparative effectiveness: The comparative effectiveness trial conducted in the last phase of the study met the planned enrollment per statistical design, with 178 patients in the multidisciplinary arm and 348 in the serial care arm. The multidisciplinary cohort had older age and a higher percentage of racial minorities, with a higher proportion of stage IV patients in the serial care arm. CONCLUSIONS: This study demonstrates a comprehensive implementation of a multidisciplinary model of lung cancer care, which will advance the science behind implementing this much-advocated clinical care model.

'One-stop shop': lung cancer patients' and caregivers' perceptions of multidisciplinary care in a community healthcare setting.

BACKGROUND: Multidisciplinary care is rarely practiced in community healthcare settings where the majority of patients receive lung cancer care in the US. We sought direct input from patients and their informal caregivers on their experience of lung cancer care delivery. METHODS: We conducted focus groups of patient and caregiver dyads. Patients had received care for lung cancer in or out of a multidisciplinary thoracic oncology clinic coordinated by a nurse navigator. Focus groups were audiotaped, transcribed, and analyzed using Creswell's 7-step process. Recurring overlapping themes were developed using constant comparative methods within the Grounded Theory framework. RESULTS: A total of 46 participants were interviewed in focus groups of 5 patient-caregiver dyads. Overlapping themes were a perception that multidisciplinary care improved physician collaboration, patient-physician communication, and patient convenience, while reducing redundancy in testing. Improved coordination decreased confusion, stress, and anxiety. Negative experience of serial care included poor communication among physicians, insensitive communication about illness, delays in diagnosis and treatment, misdiagnosis, and mistreatment. Physician-to-physician communication and patient education were suggested areas for improvement in the multidisciplinary model. CONCLUSIONS: Multidisciplinary care was perceived as more patient-centered, effective, safe, and efficient than standard serial care. It was also believed to improve the timeliness of care and equitable access to high quality care. Additional studies to compare these perspectives to those of other key stakeholders, including clinicians, hospital administrators and representatives of third party payers, will facilitate better understanding of the role of multidisciplinary care programs in lung cancer care delivery.

Preoperative Evaluation of Lung Cancer in a Community Health Care Setting.

BACKGROUND: We examined the presurgical evaluation of suspected lung cancer patients in a community-based health care system to establish current benchmarks of care that will lay the groundwork for an evidence-based quality improvement project. METHODS: We retrospectively reviewed clinical records of all recipients of lung resection at two institutions, and classified all lung cancer relevant procedures into five "nodal points": lesion detection, diagnostic biopsy, radiologic staging, invasive staging, and treatment. We analyzed the frequency of passage through each nodal point, the time intervals between nodal points, and the use of staging modalities. RESULTS: Of 614 eligible patients, 92% had lung cancer, 5% had a non-lung primary tumor, 3% had a benign lesion. Six percent received preoperative therapy; 39% of resections were minimally invasive. Ninety-eight percent of patients had a preoperative computed tomography (CT) scan, 27% had no preoperative diagnostic procedure, 22% had no preoperative positron emission tomography (PET)/CT scans, and 88% had no invasive preoperative staging test. Only 10% had trimodality staging with CT, PET/CT, and invasive staging. Twenty-one percent of patients who had an invasive staging test had mediastinal nodal metastasis at resection. The median duration (interquartile range) from initial lesion identification to resection was 84 days (43 to 189) days; from lesion identification to diagnostic biopsy, 28 days (7 to 96); and from diagnostic biopsy to surgery, 40 days (26 to 69). CONCLUSIONS: There is opportunity for improvement in the thoroughness, accuracy, and timeliness of preoperative evaluation of suspected lung cancer patients in this community cohort. Better coordination of care may significantly improve these benchmarks.