Onco-primary care networking to support TEAM-based care - the ONE TEAM Study

项目总结 自从医学研究所(IOM)发布了这份开创性的报告以来，从癌症患者到癌症幸存者： 在13年前的过渡中迷失，在理解健康问题方面取得了实质性进展 影响癌症幸存者，但在提供生存护理方面几乎没有变化。那里仍然有一个 初级保健提供者和肿瘤护理团队之间的脱节导致了持续的问题 对癌症幸存者实施风险分层生存护理。 随着癌症治疗的进步和存活率的提高，死于心血管疾病的风险 对于许多幸存者来说，(心血管疾病)现在已经超过了癌症。虽然癌症治疗可能会导致这种风险，但它是 通常是不可修改的因素(例如，遗传、衰老)以及可修改的生活方式行为的汇编 (例如，饮食、运动)导致癌症和心血管疾病(CVD)。由于缺乏主要的 护理提供者(PCP)在癌症护理团队中的集成以及时间限制和难以跟上 对于内科肿瘤学家来说，快速发展的非癌症疗法有一个推断的较低优先级 共病管理。 我们将确定多水平iGuide干预和上调的iGuide2的有效性 干预与常规护理对主要结局的影响比较。理论驱动、自我指导的iGuide 干预包括患者级组件(视频片段、面向患者的网络研讨会)和PCP级 组件(电子健康记录[EHR]自动化癌症专家-PCP信函、远程教育系列和 自动提醒)。升级的iGuide2干预包括量身定做的患者级别的视频片段 和有针对性的EHR专家-PCP沟通。 One Team智能设计研究的主要结果是(1)医疗效果数据和 信息集(HEDIS)三种心血管合并症(高血压、分型)的管理质量措施 2.糖尿病、高胆固醇血症)；(2)药物治疗 使用覆盖天数比例(PDC)评估遵从性评估药房再灌装数据；以及(3)患者-提供者 沟通(癌症护理中以患者为中心的沟通)。次要目标包括探索 在干预的每个层面中的缓和和中介因素，以患者为中心的结果的支持， 卫生保健使用、提供者激活的措施以及多层次干预所产生的护理成本。 该项目的总体目标是通过以下方式优化个人的管理和成果 癌症，包括治疗期间和治疗后，并开发一种可以 在其他卫生保健系统中推广、适应和推广。拟议的One Team研究汇集了 一个多学科的研究团队，在生存研究方面拥有必要的专业知识和经验， 人口与行为科学、初级保健、肿瘤学和生物统计学。这次干预的结果将是 对促进癌症幸存者的医疗保健服务具有重要意义。

PROJECT SUMMARY Since the Institute of Medicine (IOM) released the seminal report, From Cancer Patient to Cancer Survivor: Lost in Transition 13 years ago, there has been substantial progress in understanding the health issues affecting cancer survivors, yet little has changed regarding survivorship care delivery. There remains a disconnect between primary care providers and oncology care teams that has led to persistent problems implementing risk-stratified survivorship care for cancer survivors. With advances in cancer therapy and improved survival rates, the risk of death from cardiovascular disease (CVD) now exceeds that of the cancer for many survivors. While cancer therapy may contribute to this risk, it is generally a compilation of non-modifiable factors (i.e., genetics, aging), as well as modifiable lifestyle behaviors (i.e., diet, exercise) that lead to both the cancer and to cardiovascular disease (CVD). With the lack of primary care provider (PCP) integration in the cancer care team and time constraints and difficulty keeping up with rapidly evolving non-cancer therapeutics for medical oncologists, there is an inferred lower priority for comorbidity management. We will determine the effectiveness of the multi-level iGuide intervention and the up-titrated iGuide2 intervention compared with usual care on the primary outcomes. The theory-driven, self-guided iGuide intervention consists of patient-level components (video vignettes, patient-facing webinars) and PCP-level components (electronic health record [EHR] automated cancer specialist-PCP letter, tele-education series, and automated reminders). The up-titrated iGuide2 intervention consists of tailored patient-level video vignettes and targeted EHR specialist-PCP communication. The primary outcomes of the ONE TEAM SMART-design study are (1) Healthcare Effectiveness Data and Information Set (HEDIS) quality measures of management of the three CVD comorbidities (hypertension, type 2 diabetes mellitus, hypercholesterolemia) based upon laboratory and clinical measurement; (2) medication adherence assessed pharmacy refill data using Proportion of Days Covered (PDC); and (3) patient-provider communication (Patient-Centered Communication in Cancer Care). Secondary aims include exploring moderating and mediating factors in each level of the intervention, support of patient-centered outcomes, health care use, measures of provider activation, and costs of care resulting from the multi-level intervention. The overarching goal of this proposed project is to optimize the management and outcomes of individuals with cancer, both during and after treatment, and to develop a ‘low-touch’ multi-level intervention that can be generalized, adapted and scaled in other health care systems. The proposed ONE TEAM study brings together a multi-disciplinary research team with the necessary expertise and experience in survivorship research, population and behavioral science, primary care, oncology, and biostatistics. Results from this intervention will have important implications in the advancement of healthcare delivery for cancer survivors.