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。癌症冲浪者有独特的医疗保健需求，包括严重迟到的风险， 正在进行的监视，生活方式修改以减少第二种癌症风险和社会心理支持。几乎 70％被认为是“复杂的癌症存活”，因为它们至少有一个合并症 除癌症外。合并症对提供优质癌症护理的交付构成了重大挑战 不利影响并受到癌症治疗的影响。服务不足的患者负担最高 多种慢性疾病的情况，在癌症治疗期间和之后发生较差的结果的风险增加。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， 通过增强沟通和协作，他们的健康成果和护理过渡可能会得到改善 在他们的肿瘤学家和初级保健提供者（PCP）之间。这项研究测试并评估了新颖的共享 复杂癌症生存的护理模型，称为优化（肿瘤学 - 主要护理伙伴关系以改善 德克萨斯州休斯敦最大的安全网医疗系统中的全面生存护理）。三百 新诊断的乳腺癌，GI和血液学癌症患者正在接受治疗意图和 在癌症治疗期间需要进行持续管理的合并症将完成基线调查 并随机分配以优化或通常的医疗服务（UMC）。接受UMC的患者将收到他们的 癌症治疗，按照其肿瘤科医生的指示，即主动治疗结束时的冲浪护理计划（SCP） 并根据国家准则与肿瘤科医生进行监视访问。优化的患者意愿1） 肿瘤学护士导航员在诊断时分配给了他们的护理团队，以促进肿瘤学家PCP通信 和护理的连续性； 2）在整个癌症的肿瘤学家和PCP之间接受协调的护理 通过结构化沟通和转诊过程制备的治疗和监视； 3）收到一个 纳入合并症管理的治疗结束时的生存护理计划（SCP）；并且，4）收到 风险分层的共享治疗后监视模型，其中一个或多个常规肿瘤学家跟随 - UP访问被PCP访问所取代。 AIM 1评估优化对患者慢性疾病自我的影响 管理（主要结果）和生活质量（次要结果）。 AIM 2探索优化的效果 在主动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。 AIM 3检查效果 优化肿瘤学家和PCP的护理和协调。 AIM 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 生存诊断点，并寻求开发临床基础设施以支持护理的连续性 通过治疗后生存制度癌症诊断。如果发现有效，则可以将优化扩展到其他 癌症，点燃了潜在的研究领域。它也可能在其他方面产生重大的下游影响 医疗环境通过增强从专业到初级保健的护理过渡。