Evaluating Different Types of Cancer Survivorship Care [Internet]

Excerpt

Background: With nearly 15.5 million cancer survivors in the United States, gains in survival have created a need for high-quality posttreatment care. Cancer survivors suffer from late and long-term effects of their disease and its treatment, and the health care system must be able to care for these issues in a way that addresses patients' preferences for care and their priorities for long-term outcomes. Survivorship care, which encompasses the follow-up care, services, resources and monitoring that cancer survivors receive after treatment has ended, is an important aspect of the cancer care trajectory that can improve patients' health outcomes and quality of life (QOL) over the long term. It focuses on the health and life of a cancer patient posttreatment and addresses physical, psychosocial and economic issues, including the lasting effects from treatment, patient's self-efficacy and ability to manage their care posttreatment, and issues related to insurance and financial challenges resulting from care.

Objectives: The primary objective of the study was to compare the quality of 3 models of survivorship care and their impact on survivorship-care related patient-centered outcomes (PCOs) using a newly developed survivorship care quality framework (SCQF) and accompanying survivorship care quality index (SCQI) and validated measures of patient-prioritized PCOs.

Methods: We completed 3 phases of work. (1) We developed the SCQF based on data from 170 focus groups with breast, colorectal and prostate cancer survivors and created a measurement tool, the SCQI, using exploratory and confirmatory factor analysis. The SCQI comprises 9 factors of quality with 42 total metrics. (2) We identified 3 models of survivorship care based on data from an environmental scan of 232 high-performing cancer centers with survivorship care services. The models are: (a) Specialized Consultative Care, (b) Specialized Longitudinal Care, and (c) Oncology Embedded Care. (3) We conducted comparative effectiveness research assessing the quality of care across the 3 survivorship models using the SCQI as our quality instrument. We also examined the impact of the models on patient-reported PCOs: cancer-related QOL, self-efficacy, which is defined as patients' confidence in managing symptoms and health care concerns related to their health posttreatment, health care utilization of 4 providers types, and patient satisfaction with care. The CER employed a longitudinal, observational study design. We recruited 32 high-performing cancer centers to enroll survivors into the study. We collected data on quality and PCOs over 6 months at 4 points in time: (1) T0_a, occurring immediately before the initial survivorship care visit; (2) T0_b at 1 week following the survivorship care visit; (3) T1 at 3 months; and (4) T2 at 6 months. We had a final sample of 991 patients at the first point of data collection and 777 patients at month 6.

Results: The formative work contributes substantive research to the field in the form of a the SCQI, which can be used as both a quality metric and a toolkit for improvement, and the identification of 3 models of survivorship care currently in use in the field. The CER compares the quality and impact of survivorship care across the 3 models, providing ground-breaking results that can substantively change survivorship cancer care. In the CER, bivariate analyses show that cancer centers are struggling to provide high-quality survivorship care in most of the 9 quality of care factors, with most scores registering in the 50% to70% range (range of 0% to 100%). Multivariable model results show the Specialized Consultative Model is associated with better quality of care in cross-sectional analyses at week 1, but the Oncology Embedded Model is associated with better quality of care over time. For QOL, patients receiving care in the Specialized Consultative Model had significantly lower physical concerns than their counterparts receiving care in the other 2 models and significantly lower emotional/social concerns than patients in the Specialized Longitudinal Model. Survivorship care appears to have a significant impact regardless of care model for self-efficacy. Bivariate analyses show significant improvement from baseline to month 6 for self-efficacy within each model. However, there were no differences across models over time. For health care utilization over time, patients in the Specialized Longitudinal Model had significantly fewer visits to their PCPs than those in the consultative model. Finally, patients in all 3 models were very satisfied with their care, reporting percentages in the high 90th percentile.

Conclusions: Survivorship care clearly provides benefits to survivors, but different models perform better on different outcomes. The Oncology Embedded Model has higher patient-reported quality scores, suggesting the importance of being able to develop long-term, trusting relationships with providers. The Specialized Consultative Model reported better QOL scores, suggesting a highly-specialized approach can address specific QOL concerns better than the longitudinal models in the immediate weeks posttreatment. In both cases, results reinforce that having some guidance for cancer centers on how to organize care can improve outcomes and provide blueprints for how care can be developed within specific contexts and patient populations.

Limitations: The study faces several limitations. Results may not be generalizable to a broader population of cancer survivors as participants were disproportionately White and privately insured. Moreover, the cancer centers in the study were high performers, which may reduce generalizability to all cancer centers. The research design was a quasi-experimental, longitudinal design and may not control for unknown confounders. In addition, our model comparators had some overlap in characteristics which may confound the examination of differences across models.