Pragmatic Trial - Telehealth Research and Innovation for Veterans with Cancer (THRIVE).

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Four cancers – lung, colorectal, prostate and breast – account for nearly half of all cancer deaths among men and women in the United States. Social determinants of telehealth (SDTH), such as race/ethnicity, poverty and rurality, individually and in additive or synergistic combinations play an important role in access to and outcomes from cancer care, often accounting for the observed cancer care disparities. Veterans Health Administration (VA) is the largest integrated provider of cancer care in the US and provides state of the art cancer care to millions of veterans. Yet even within VA, routinely praised for its equal access to care model, disparities in cancer care persist. However, while VA serves a population at risk for SDTH driven healthcare disparities, it also leverages the advantages of an integrated national single-payer system, such as care coordination and telehealth, to improve health equity. Widespread use of telehelath in oncology creates both challenges and opportunities to expand access and improve care. In some cases, however, reliance on telehealth may widen the “digital divide” for those with limited ability to access it. A major knowledge gap exists regarding the optimal way to integrate telehealth into oncology practice across the care continuum. Our overarching aim is to improve the quality and equity of cancer care across the United States by leveraging lessons learned applying telehealth treating veterans with cancer in VA’s integrated health care system. The objective of the pragmatic trial to test the effectiveness of an existing, ongoing clinical service, the VA National TeleOncology program (NTO), a multilevel telehealth population health management program. We propose a stepped wedge, cluster randomized, hybrid effectiveness-implementation study of NTO among veterans diagnosed with prostate, lung, colon and breast cancers in VA. Using the NIMHD Health Disparities Research Framework, we will employ mixed methods to explore the association across SDTH between NTO and 1) service delivery outcomes, 2) hierarchical cancer outcomes, and 3) implementation outcomes. Specifically, the aims of the pragmatic trial are to: (1) Evaluate the effect of a comprehensive multilevel virtual oncology program to promote telehealth engagement on stakeholder (patient, provider, administrator) cancer care experience across SDTH; (2) Evaluate the effect of a comprehensive, multilevel virtual oncology program on quality of cancer care in veterans diagnosed with lung, colorectal, prostate and breast cancer across SDTH; and (3) Determine the impact and cost of a comprehensive multilevel teleoncology program. Our proposed hybrid effectiveness implementation trial to evaluate a comprehensive virtual oncology program to promote telehealth engagement and health equity has high potential for scalability and public health impact both within and outside of VA.