OPTIMISE: A Shared Care Approach for Improving Comprehensive Care of Cancer Patients with Comorbidities in A Safety-Net System

OPTIMISE：一种共享护理方法，可在安全网系统中改善患有合并症的癌症患者的综合护理

• 批准号: 10175490
• 负责人: Hoda J Badr
• 金额: $ 65.77万
• 依托单位: BAYLOR COLLEGE OF MEDICINE
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-06-01 至 2026-05-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10175490
• 关键词: Accident and Emergency department; Address; Adherence; Adoption; Affect; Aftercare; Area; Attitude; Baseline Surveys; Cancer Patient; Cancer Survivor; Cancer Survivorship; Caring; Chronic; Chronic Disease; Clinic Visits; Clinics and Hospitals; Collaborations; Communication; Complex; Comprehensive Health Care; Continuity of Patient Care; Data; Diagnosis; Disease Management; Disease-Free Survival; Face; Feedback; Future; Goals; Guidelines; Health; Healthcare; Healthcare Systems; Hematologic Neoplasms; Individual; Interruption; Interview; Knowledge; Late Effects; Lead; Life Style Modification; Low income; Malignant Neoplasms; Malignant neoplasm of gastrointestinal tract; Medical; Methods; Modeling; Monitoring for Recurrence; Newly Diagnosed; Oncologist; Oncology; Oncology Nurse; Outcome; Outcome Assessment; Pathway interactions; Patient Care; Patients; Preventive care; Primary Health Care; Process; Protocols documentation; Provider; Psychosocial Assessment and Care; Public Hospitals; Qualitative Evaluations; Quality of life; Randomized; Randomized Controlled Trials; Reach, Effectiveness, Adoption, Implementation, and Maintenance; Recurrence; Reporting; Research; Resources; Risk; Second Primary Cancers; Self Management; Structure; Supportive care; Surveillance Modeling; System; Testing; Thinking; Time; Translations; Uninsured; Visit; Visiting Nurse; active method; base; breast cancer diagnosis; cancer care; cancer diagnosis; cancer risk; cancer therapy; care coordination; care providers; care systems; chronic care model; clinical care; clinical infrastructure; clinical practice; collaborative care; comorbidity; ethnic minority population; experience; follow-up; health care service utilization; implementation outcomes; improved; malignant breast neoplasm; medical specialties; medically underserved; multiple chronic conditions; novel; patient subsets; prevent; primary outcome; racial and ethnic; risk stratification; safety net; scale up; secondary outcome; survivorship; trend; uptake

PROJECT SUMMARY. Cancer survivors have unique healthcare needs including risk for serious late effects, ongoing surveillance, lifestyle modifications to reduce second cancer risk, and psychosocial support. Nearly 70% are considered “complex cancer survivors” because they have at least one comorbid chronic condition in addition to cancer. Comorbidities pose significant challenges to the delivery of quality cancer care because they adversely affect and are affected by cancer treatment. Medically underserved patients have the highest burden of multiple chronic conditions and are at increased risk for poor outcomes during and after cancer treatment. As medically underserved complex cancer patients may lack healthcare knowledge and access to supportive care, their health outcomes and care transitions might be improved by enhancing communication and collaboration between their oncologists and primary care providers (PCPs). This study tests and evaluates a novel shared care model for complex cancer survivors called OPTIMISE (Oncology-Primary Care Partnership to Improve Comprehensive Survivorship Care) in the largest safety-net healthcare system in Houston, TX. Three-hundred newly diagnosed breast, GI, and hematological cancer patients who are being treated with curative intent and who have comorbidities requiring ongoing management during cancer treatment will complete baseline surveys and be randomized to either OPTIMISE or Usual Medical Care (UMC). Patients receiving UMC will receive their cancer treatment, as directed by their oncologist, a survivorship care plan (SCP) at the end of active treatment, and surveillance visits with their oncologist based on national guidelines. Patients in OPTIMISE will 1) have an oncology nurse navigator assigned to their care team at diagnosis to facilitate oncologist-PCP communication and continuity of care; 2) receive coordinated care between their oncologist and PCP throughout cancer treatment and surveillance facilitated by a structured communication and referral process; 3) receive a survivorship care plan (SCP) at the end of treatment that incorporates comorbidity management; and, 4) receive a risk-stratified shared care model of post-treatment surveillance where one or more routine oncologist follow- up visits is replaced by a PCP visit. AIM 1 evaluates the impact of OPTIMISE on patient chronic disease self- management (primary outcome) and quality of life (secondary outcome). Aim 2 explores the effects of OPTIMISE on healthcare use and patient unmet needs during and after active cancer treatment. Aim 3 examines the effects of OPTIMISE on oncologist and PCP attitudes and coordination of care. Aim 4 seeks to elucidate patient- and system-level factors that may influence implementation outcomes. OPTIMISE shifts the timing of thinking about survivorship to point of diagnosis and seeks to develop a clinical infrastructure to support continuity of care from cancer diagnosis through post-treatment survivorship. If found effective, OPTIMISE could be expanded to other cancers, igniting a potentially rich area of research. It may also have significant downstream impact in other medical settings by enhancing care transitions from specialty to primary care.

项目摘要。癌症幸存者有独特的医疗保健需求，包括严重后期影响的风险， 持续监测、改变生活方式以降低第二次癌症风险以及社会心理支持。几乎 70% 的人被认为是“复杂癌症幸存者”，因为他们至少患有一种慢性病 除了癌症。合并症对提供优质癌症护理构成重大挑战，因为它们 对癌症治疗产生不利影响并受到癌症治疗的影响。医疗服务不足的患者负担最重 患有多种慢性疾病，并且在癌症治疗期间和治疗后出现不良结果的风险增加。作为 医疗服务不足的复杂癌症患者可能缺乏医疗保健知识和获得支持性护理的机会， 通过加强沟通和协作，可以改善他们的健康结果和护理转变 肿瘤科医生和初级保健提供者 (PCP) 之间的交流。这项研究测试并评估了一部共享的小说 针对复杂癌症幸存者的护理模式称为 OPTIMIZE（肿瘤学-初级护理合作伙伴关系以改善 德克萨斯州休斯顿最大的安全网医疗保健系统中的综合幸存者护理）。三百 新诊断的乳腺癌、胃肠道癌和血液癌患者正在接受治疗性治疗，并且 在癌症治疗期间患有需要持续管理的合并症的人将完成基线调查 并被随机分配至“优化”或“常规医疗护理”(UMC)。接受 UMC 的患者将收到他们的 癌症治疗，按照肿瘤科医生的指导，积极治疗结束时的生存护理计划（SCP）， 根据国家指南对肿瘤科医生进行监测访问。 OPTIMIZE 中的患者将 1) 有 肿瘤科护士导航员在诊断时分配给他们的护理团队，以促进肿瘤科医生与 PCP 的沟通 和护理的连续性； 2) 在整个癌症过程中接受肿瘤科医生和 PCP 之间的协调护理 通过结构化沟通和转诊流程促进治疗和监测； 3）收到一个 治疗结束时的生存护理计划（SCP），其中包括合并症管理；以及，4) 接收 一种治疗后监测的风险分层共享护理模式，其中一名或多名常规肿瘤学家遵循 上访被 PCP 访视取代。 AIM 1 评估 OPTIMIZE 对患者慢性病自我评估的影响 管理（主要结果）和生活质量（次要结果）。目标 2 探索 OPTIMIZE 的效果 关于积极癌症治疗期间和之后的医疗保健使用和患者未满足的需求。目标 3 检查效果 OPTIMIZE 对肿瘤科医生和 PCP 态度以及护理协调的影响。目标 4 旨在阐明患者和 可能影响实施结果的系统级因素。优化改变思考的时机 幸存者到诊断点，并寻求开发临床基础设施以支持从 通过治疗后存活率进行癌症诊断。如果发现有效，优化可以扩展到其他 癌症，点燃了一个潜在丰富的研究领域。它还可能对其他下游领域产生重大影响 通过加强从专科护理到初级护理的医疗过渡。