Neoplasms

Skin and Connective Tissue Diseases

All Conditions

Digestive System Diseases

Breast Neoplasms

Colorectal Neoplasms

Intestinal Neoplasms

Gastrointestinal Neoplasms

Digestive System Neoplasms

Gastrointestinal Diseases

Colonic Diseases

Intestinal Diseases

Rectal Diseases

Patients eligible for the study who will receive Care Coordination Strategies.

Co-located Care coordinator will use EMR-driven registry to facilitate patient transitions between primary care and oncology care and enhance teamwork through coaching and technical assistance.

Care Coordination Strategies

Simon Craddock Lee, PhD, MPH

Bijal Balasubramanian, MD, PhD

Nearly 70% of people living with cancer are "complex patients" with multiple chronic conditions who must deal not only with effects of their cancer but also continuing diseases such as diabetes, depression, hypertension, or heart disease. Care coordination strategies shown to be effective in improving outcomes for common medical conditions seen in primary care include: systematic transitions for patients to and from specialty care; intensive case management; and a team-based approach to comprehensive care. Despite an Institute of Medicine report suggesting these strategies as potential ways to improve care for cancer survivors, their implementation has not yet been evaluated for cancer survivors. Parkland Health and Hospital Systems will be implementing care coordinator strategies as part of as quality assurance/quality improvement activities, which Aim 2 and Aim 3 (research components) will evaluate. This protocol has been organized to reflect this distinction between the aims. The investigators expect no more than 1500 patients to be included in these study aims.

This project is a pragmatic trial. The investigators propose a quasi-experimental design where data will be collected both pre- and post-intervention on distinct cross-sections of patients with one or more highly prevalent ambulatory-sensitive chronic conditions (diabetes, hypertension, chronic lung disease, chronic kidney disease, depression, or heart disease) and newly diagnosed with breast, colorectal, or gynecologic cancers (complex cancer survivors) in the Parkland Health \& Hospital system (Dallas, TX).

Guided by the "Primary Care Change Model", Parkland will implement evidence-based care coordination strategies to improve care for complex cancer survivors in this integrated safety-net system as a part of quality assurance/quality improvement activities (Aim 1), then this study will comprehensively evaluate how these strategies are implemented in the safety-net setting (Aim 3), and whether implementing these strategies improves care coordination and care outcomes (Aim 2) within the Parkland Health and Hospital System. Investigators expect approximately 1000 new survivors with ≥ 1 prevalent chronic condition to be eligible. The project does not include patients diagnosed with in situ and metastatic disease (Stages 0 and IV) due to insufficient evidence for routine follow-up and management; many of the latter continue indefinitely on active treatment for symptom management. The chronic conditions selected for inclusion are the most prevalent conditions cancer survivors have at Parkland as well as nationally.

* Aim 1: (Quality Assurance/ Improvement) Implement a system-level EMR-driven intervention for approximately 1000 complex cancer survivors at Parkland, combining three evidence-based care coordination strategies; (1) EMR-driven registry to facilitate patient transitions between primary care and oncology care, (2) co-locate a nurse practitioner trained in care coordination within a complex care team, and (3) enhance teamwork through coaching and technical assistance;
* Aim 2: (Research component) Test effectiveness of the strategies on system- and patient-level outcomes using a rigorous, quasi-experimental design with outcomes measured before and after implementation;
* Aim 3: (Research Component) Elucidate system and patient factors that facilitate or hinder implementation and result in differences in experiences of care coordination between complex patients with and without cancer. Investigators will collect quantitative (EMR data, patient surveys) and qualitative (structured observations, patient and provider interviews, EMR audits) data throughout.

Care Coordination for Complex Cancer Survivors in an Integrated Safety Net System

Care Coordination for Complex Cancer Survivors in an Integrated Safety Net System (Project Connect)

Proportion of complex cancer survivors meeting quality of care guidelines for multiple chronic conditions and follow-up cancer surveillance

Patient-reported perception of care coordination was measured using the Coordination of Care dimension adapted from the validated Picker Patient Experience Questionnaire. The adapted version used in this study consisted of eight items and was administered at baseline and at 6 and 12-months of follow-up. Each item is weighted from 1 to 3 and the cumulative care coordination score is the summation of all the survey items on a scale of 8 to 24. A Lower score indicates better care coordination.

University of Texas Southwestern Medical Center

Principal Investigator

Patients in the Retrospective Comparison group and Non-Cancer Historical Group were derived through EHR data extraction with no direct engagement with the study team. Adverse Events were not monitored/assessed for participants from these groups.

Patients with a primary diagnosis of stage I-III breast or colorectal cancer between September 1, 2017, and April 31, 2021 and a diagnosis of at least one comorbid chronic conditions (diabetes, hypertension, heart disease, chronic kidney disease, and chronic obstructive pulmonary disease). Eligible patients received care coordination strategies to facilitate patient transitions between primary care and oncology care.

Project CONNECT Care Coordination

Patients with a primary diagnosis of stage I-III breast or colorectal cancer between January 1, 2010 - December 31, 2016 and a diagnosis of at least one comorbid chronic conditions (diabetes, hypertension, heart disease, chronic kidney disease, and chronic obstructive pulmonary disease).The retrospective cohort serves as a comparison group to the care coordination cohort.

Retrospective Comparison Group

A random sample of 1,000 patients seen January 1, 2010-December 31, 2016 with no history of cancer, at least two chronic conditions (diabetes, hypertension, chronic lung dis-ease, chronic kidney disease, or heart disease). This arm is used as a control to the retrospective cancer group.

Non-Cancer Retrospective Group

Total

Age, Continuous

Sex: Female, Male

Ethnicity (NIH/OMB)

Race (NIH/OMB)

Survey accrual was lower than target (N=402). Revised power calculations for the analysis of the patient-level primary outcome measure, change in patient perception of care coordination, demonstrated the actual survey sample (N=294) was large enough to detect meaningful improvement.

Simon Lee

COVID pandemic prevented community health system from being able to extract these data within study timeframe which prevented reporting and analysis on this outcome.

Proportion of Complex Cancer Survivors Meeting Quality of Care Guidelines for Chronic Conditions and Follow-up Cancer Surveillance

Baseline Survey

6-Month Survey

12-Month Survey

Patients with a primary diagnosis of stage I-III breast or colorectal cancer between September 1, 2017, and April 31, 2021 and a diagnosis of at least one of the comorbid chronic conditions (diabetes, hypertension, heart disease, chronic kidney disease, and chronic obstructive pulmonary disease). Eligible patients received care coordination strategies.

This analysis included participants who completed at least one assessment with all care coordination items completed.

Patient Perception of Care (Scale)

A random sample of 1,000 patients seen January 1, 2010-December 31, 2016 with no history of cancer, at least two chronic conditions (diabetes, hypertension, chronic lung dis-ease, chronic kidney disease, or heart disease). This arm is used as a control to the retrospective comparison group.

Spots Global Cancer Trial Database for care coordination strategies