Multilevel factors affecting quality: examples from the cancer care continuum

J Natl Cancer Inst Monogr. 2012 May;2012(44):11-9. doi: 10.1093/jncimonographs/lgs005.


The complex environmental context must be considered as we move forward to improve cancer care and, ultimately, patient and population outcomes. The cancer care continuum represents several care types, each of which includes multiple technical and communication steps and interfaces among patients, providers, and organizations. We use two case scenarios to 1) illustrate the variability, diversity, and interaction of factors from multiple levels that affect care quality and 2) discuss research implications and provide hypothetical examples of multilevel interventions. Each scenario includes a targeted literature review to illustrate contextual influences upon care and sets the stage for theory-informed interventions. The screening case highlights access issues in older women, and the survivorship case illustrates the multiple transition challenges faced by patients, families, and organizations. Example interventions show the potential gains of implementing intervention strategies that work synergistically at multiple levels. While research examining multilevel intervention is a priority, it presents numerous study design, measurement, and analytic challenges.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Community Networks
  • Continuity of Patient Care / standards*
  • Continuity of Patient Care / trends*
  • Early Detection of Cancer / standards*
  • Early Detection of Cancer / trends
  • Female
  • Health Services Research
  • Humans
  • Life Style
  • Mass Media
  • Medicare
  • Neoplasms* / diagnosis
  • Neoplasms* / prevention & control
  • Neoplasms* / therapy
  • Patient Acceptance of Health Care*
  • Patient Care Team / standards
  • Patient Care Team / trends
  • Precision Medicine
  • Primary Prevention / standards
  • Primary Prevention / trends
  • Quality of Health Care* / standards
  • Quality of Health Care* / trends
  • Social Environment*
  • Social Support
  • United States
  • Unnecessary Procedures