Fragmentation of Care Among Black Women With Breast Cancer and Comorbidities: The Role of Health Systems

2021 ◽  
Vol 17 (5) ◽  
pp. e637-e644 ◽  
Author(s):  
Michelle Doose ◽  
Janeth I. Sanchez ◽  
Joel C. Cantor ◽  
Jesse J. Plascak ◽  
Michael B. Steinberg ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Primary Care ◽  
Black Women ◽  
Health System ◽  
Health Systems ◽  
Care Coordination ◽  
Surgical Care ◽  
Primary Care Visit ◽  
Practice Setting ◽  
Care Fragmentation

PURPOSE: Black women are disproportionately burdened by comorbidities and breast cancer. The complexities of coordinating care for multiple health conditions can lead to adverse consequences. Care coordination may be exacerbated when care is received outside the same health system, defined as care fragmentation. We examine types of practice setting for primary and breast cancer care to assess care fragmentation. MATERIALS AND METHODS: We analyzed data from a prospective cohort of Black women diagnosed with breast cancer in New Jersey who also had a prior diagnosis of diabetes and/or hypertension (N = 228). Following breast cancer diagnosis, we examined types of practice setting for first primary care visit and primary breast surgery, through medical chart abstraction, and identified whether care was used within or outside the same health system. We used multivariable logistic regression to explore sociodemographic and clinical factors associated with care fragmentation. RESULTS: Diverse primary care settings were used: medical groups (32.0%), health systems (29.4%), solo practices (23.7%), Federally Qualified Health Centers (8.3%), and independent hospitals (6.1%). Surgical care predominately occurred in health systems (79.8%), with most hospitals being Commission on Cancer–accredited. Care fragmentation was experienced by 78.5% of Black women, and individual-level factors (age, health insurance, cancer stage, and comorbidity count) were not associated with care fragmentation ( P > .05). CONCLUSION: The majority of Black breast cancer survivors with comorbidities received primary care and surgical care in different health systems, illustrating care fragmentation. Strategies for care coordination and health care delivery across health systems and practice settings are needed for health equity.

Identifying challenges to breast cancer care coordination at urban community-based primary care clinics.

2018 ◽  
Vol 36 (7_suppl) ◽  
pp. 83-83
Author(s):  
Tamara Hamlish ◽  
Zakiya N Moton ◽  
Zuoli Zhang ◽  
Dana Sohmer ◽  
Olufunmilayo I. Olopade ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Primary Care ◽  
Care Coordination ◽  
Cancer Care ◽  
Medical Records ◽  
Primary Care Providers ◽  
Primary Care Visit ◽  
Patient Centered ◽  
Care Continuum ◽  
Cancer Specialists

83 Background: Primary care providers (PCPs) are well positioned to play a significant role in improving cancer care in the U.S. and achieving the Institute of Medicine (IOM) recommendation for patient-centered, coordinated, comprehensive cancer care across the care continuum. This is particularly important in underserved communities where fragmented care contributes to widening disparities in cancer mortality. However, PCPs can face considerable challenges delivering cancer care. This research examines challenges to breast cancer survivorship (BCS) care coordination at federally qualified health centers (FQHCs). Methods: We conducted a chart review at five Chicago FQHCs to assess BCS-related follow-up care provided by PCPs. We reviewed patient electronic medical records for documentation of breast cancer-related health information by the PCP and for documentation from cancer specialists, including consultant notes, pathology reports, and treatment histories. Based on BC ICD -9 codes we identified 109 patients who had a BC diagnosis within five years and a primary care visit at one of the five FQHCS within 2 years. Results: The patient population was primarily comprised of African Americans (81%), with 16% Hispanic, and 4% Asian or non-Hispanic White. Mean age at diagnosis was 55 years with 30% diagnosed < 50 years. Medicaid (59%) was the most common health insurance. More than half of the patients had ≥1 chronic disease. Critical clinical BC information was missing from patient medical records, including BC pathology (65%), mammogram (60%), last clinical breast examination (49%), and cancer specialist notes (45%). Documentation of family history and genetic counseling were missing from 76% and 98% of the records, respectively. Conclusions: Our data indicate that PCPs at FQHCs currently have a limited role in delivering IOM recommended patient-centered, coordinated, comprehensive cancer care across the care continuum. The research results underscore a need for improvement in two key areas: 1) support for PCPs to build capacity in BCS care and 2) enhanced communication and care coordination between cancer specialists and PCPS in order to make PCPs an active part of the BCS care team.

scholarly journals The effectiveness of different patient referral systems to shorten waiting times for elective surgeries: systematic review

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Dimuthu Rathnayake ◽  
Mike Clarke
Keyword(s):  
Primary Care ◽  
Health Systems ◽  
Elective Surgery ◽  
Waiting Times ◽  
Surgical Care ◽  
High Income ◽  
Surgical Patients ◽  
Timely Access ◽  
Referral Systems

Abstract Background Long waiting times for elective surgery are common to many publicly funded health systems. Inefficiencies in referral systems in high-income countries are more pronounced than lower and middle-income countries. Primary care practitioners play a major role in determining which patients are referred to surgeon and might represent an opportunity to improve this situation. With conventional methods of referrals, surgery clinics are often overcrowded with non-surgical referrals and surgical patients experience longer waiting times as a consequence. Improving the quality of referral communications should lead to more timely access and better cost-effectiveness for elective surgical care. This review summarises the research evidence for effective interventions within the scope of primary-care referral methods in the surgical care pathway that might shorten waiting time for elective surgeries. Methods We searched PubMed, EMBASE, SCOPUS, Web of Science and Cochrane Library databases in December-2019 to January-2020, for articles published after 2013. Eligibility criteria included major elective surgery lists of adult patients, excluding cancer related surgeries. Both randomised and non-randomised controlled studies were eligible. The quality of evidence was assessed using ROBINS-I, AMSTAR 2 and CASP, as appropriate to the study method used. The review presentation was limited to a narrative synthesis because of heterogeneity. The PROSPERO registration number is CRD42019158455. Results The electronic search yielded 7543 records. Finally, nine articles were considered as eligible after deduplication and full article screening. The eligible research varied widely in design, scope, reported outcomes and overall quality, with one randomised trial, two quasi-experimental studies, two longitudinal follow up studies, three systematic reviews and one observational study. All the six original articles were based on referral methods in high-income countries. The included research showed that patient triage and prioritisation at the referral stage improved timely access and increased the number of consultations of surgical patients in clinics. Conclusions The available studies included a variety of interventions and were of medium to high quality researches. Managing patient referrals with proper triaging and prioritisation using structured referral formats is likely to be effective in health systems to shorten the waiting times for elective surgeries, specifically in high-income countries.

scholarly journals Health system experiences of breast cancer survivors in urban South Africa

2020 ◽  
Vol 16 ◽  
pp. 174550652094941
Author(s):  
Madeleine Lambert ◽  
Emily Mendenhall ◽  
Andrew Wooyoung Kim ◽  
Herbert Cubasch ◽  
Maureen Joffe ◽  
...  
Keyword(s):  
Breast Cancer ◽  
South Africa ◽  
Black Women ◽  
Health System ◽  
South African ◽  
Breast Cancer Survivors ◽  
Radiation Treatment ◽  
African Women ◽  
Total Mastectomy ◽  
South African Women

Background: Breast cancer is the most common cancer globally and among South African women. Women from socioeconomically disadvantaged South African communities more often present later and receive total mastectomy compared to those from more affluent communities who have more breast conserving surgery (which is less invasive but requires mandatory radiation treatment post-operatively). Standard chemotherapy and total mastectomy treatments are known to cause traumatizing side effects and emotional suffering among South African women; moreover, many women face limited communication with physicians and psychological support. Objective: This article investigates the experiences of women seeking breast cancer treatment at the largest public hospital in South Africa. Methods We interviewed 50 Black women enrolled in the South African Breast Cancer Study to learn more about their health system experiences with detection, diagnosis, treatment, and follow-up care for breast cancer. Each interview was between 2–3 hours, addressing perceptions, experiences, and concerns associated with breast cancer and comorbidities such as HIV and hypertension. Results: We found most women feared diagnosis, in part, because of the experience of chemotherapy and physical mutilation related to mastectomy. The importance of social support from family, religion, and clinical staff was fundamental for women coping with their condition and adhering to treatment and medication. Conclusions: These findings exemplify how interventions might promote early detection of breast cancer and better adherence to treatment. Addressing community perceptions of breast cancer, patient needs and desires for treatment, structural barriers to intensive therapies, and the burden of invasive treatments are imperative next steps for delivering better breast cancer care in Soweto and other resource-constrained settings.

scholarly journals Identifying important health system factors that influence primary care practitioners’ referrals for cancer suspicion: a European cross-sectional survey

BMJ Open ◽  
2018 ◽  
Vol 8 (9) ◽  
pp. e022904 ◽  
Author(s):  
Michael Harris ◽  
Peter Vedsted ◽  
Magdalena Esteva ◽  
Peter Murchie ◽  
Isabelle Aubin-Auger ◽  
...  
Keyword(s):  
Primary Care ◽  
Decision Making ◽  
Factor Analysis ◽  
Health System ◽  
Health Systems ◽  
European Countries ◽  
Cancer Symptoms ◽  
Referral Decision ◽  
System Factors ◽  
Primary Care Practitioners

ObjectivesCancer survival and stage of disease at diagnosis and treatment vary widely across Europe. These differences may be partly due to variations in access to investigations and specialists. However, evidence to explain how different national health systems influence primary care practitioners’ (PCPs’) referral decisions is lacking.This study analyses health system factors potentially influencing PCPs’ referral decision-making when consulting with patients who may have cancer, and how these vary between European countries.DesignBased on a content-validity consensus, a list of 45 items relating to a PCP’s decisions to refer patients with potential cancer symptoms for further investigation was reduced to 20 items. An online questionnaire with the 20 items was answered by PCPs on a five-point Likert scale, indicating how much each item affected their own decision-making in patients that could have cancer. An exploratory factor analysis identified the factors underlying PCPs’ referral decision-making.SettingA primary care study; 25 participating centres in 20 European countries.Participants1830 PCPs completed the survey. The median response rate for participating centres was 20.7%.Outcome measuresThe factors derived from items related to PCPs’ referral decision-making. Mean factor scores were produced for each country, allowing comparisons.ResultsFactor analysis identified five underlying factors: PCPs’ ability to refer; degree of direct patient access to secondary care; PCPs’ perceptions of being under pressure; expectations of PCPs’ role; and extent to which PCPs believe that quality comes before cost in their health systems. These accounted for 47.4% of the observed variance between individual responses.ConclusionsFive healthcare system factors influencing PCPs’ referral decision-making in 20 European countries were identified. The factors varied considerably between European countries. Knowledge of these factors could assist development of health service policies to produce better cancer outcomes, and inform future research to compare national cancer diagnostic pathways and outcomes.

scholarly journals IMPLEMENTING THE 4MS IN PRIMARY CARE: BUILDING AN AGE-FRIENDLY HEALTH SYSTEM

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S769-S769
Author(s):  
Ellen Flaherty ◽  
Terry Fulmer
Keyword(s):  
Primary Care ◽  
Health System ◽  
Health Systems ◽  
Clinical Training ◽  
Care Management ◽  
Transitional Care ◽  
Transfer Model ◽  
Term Care ◽  
Care Systems ◽  
Care Improvement

Abstract The Age Friendly Health Systems initiative is a culture change movement funded by the John A. Hartford Foundation in collaboration with the Institute for Health Care Improvement. Transforming clinical training environments into integrated geriatrics and primary care systems to become Age-Friendly Health Systems must incorporate the principles of value-based care and alternative-payment models. This symposium will discuss how the implementation of the Geriatric Interprofessional Team Transformation in Primary Care (GITT-PC) model and the Reducing Avoidable Facility Transfer Model (RAFT) in primary care will improve patient outcomes focused on the 4M’s of the Age Friendly Health System. The success of the GITT-PC model focuses on 4 Medicare reimbursable services including the Annual Wellness Visit, Transitional Care Management, Chronic Care Management and Advance Care Planning. The RAFT model focuses on What Matters Most to residents of long term care facilities and reduces ED visits and hospital transfers through elicitation of goals of care and 24 hour virtual support from an interprofessional geriatric team.

Evaluating data-driven breast surgery treatment path visualizations from registry and administrative data.

2016 ◽  
Vol 34 (7_suppl) ◽  
pp. 195-195
Author(s):  
Ravi V Atreya ◽  
Alexander S Taylor ◽  
Mia Alyce Levy
Keyword(s):  
Breast Cancer ◽  
Health System ◽  
Cancer Patients ◽  
Administrative Data ◽  
Cancer Registry ◽  
Educational Intervention ◽  
Surgical Care ◽  
Data Driven ◽  
Breast Cancer Patients ◽  
Learning Health System

195 Background: Breast cancer patients face difficult decisions about their surgical care without a full understanding of their options. The learning health system goal is to use information from the care of prior patients to inform the care of future patients. We aim to apply this concept to generate data-driven surgical paths, develop interactive path visualizations to inform patients, and evaluate their impact. Methods: We used cancer registry and administrative CPT codes for women diagnosed with stage 0-III breast cancer between FY2010-14 at a comprehensive cancer center. We generated surgical event sequences and visualized them using interactive Sankey diagram path visualizations. We will run a prospective educational intervention this winter to evaluate their impact on the shared decision making process. A web-based application will be available to patients prior to, during, and after their surgical clinic visit; we will survey their reaction pre-visit, post-visit, and post-surgery. Results: 1556 patients had 1951 surgical events in the registry and 48% started their surgical care with a breast conserving surgery while 52% began with a mastectomy. Mastectomy paths are presented in Table 1. We have developed interactive visualizations for patients to view, will be conducting our prospective educational intervention this winter, and will be ready to present preliminary results in February. Conclusions: We have been able to develop interactive, data-driven surgical path visualizations for breast cancer patients from cancer registry and administrative data. We will be conducting a prospective educational intervention to evaluate our implementation of this learning health system concept. [Table: see text]

scholarly journals Decentralization and Regionalization: Redesigning Health Systems for High Quality Maternity Care Comment on "Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries"

2020 ◽  
Author(s):  
Sanam Roder-DeWan
Keyword(s):  
Health System ◽  
Health Systems ◽  
Maternity Care ◽  
Quality Care ◽  
Surgical Care ◽  
Maternal Complications ◽  
High Quality ◽  
Middle Income ◽  
Middle Income Countries ◽  
Low And Middle Income

The question of how to optimally design health systems in low- and middle-income countries (LMICs) for high quality care and survival requires context-specific evidence on which level of the health system is best positioned to deliver services. Given documented poor quality of care for surgical conditions in LMICs, evidence to support intentional health system design is urgently needed. Iverson and colleagues address this very important question. This commentary explores their findings with particular attention to how they apply to maternity care. Though surgical maternity care is a common healthcare need, maternal complications are often unpredictable and require immediate surgical attention in order to avert serious morbidity or mortality. A discussion of decentralization for maternity services must grapple with this tension and differentiate between facilities that can provide emergency surgical care and those that can not.

scholarly journals Comorbidity Management in Black Women Diagnosed with Breast Cancer: the Role of Primary Care in Shared Care

2020 ◽  
Author(s):  
Michelle Doose ◽  
Michael B. Steinberg ◽  
Cathleen Y. Xing ◽  
Yong Lin ◽  
Joel C. Cantor ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Primary Care ◽  
Black Women ◽  
Shared Care

scholarly journals Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap

2020 ◽  
Vol 5 (10) ◽  
pp. e002539
Author(s):  
Sanam Roder-DeWan ◽  
Kojo Nimako ◽  
Nana A Y Twum-Danso ◽  
Archana Amatya ◽  
Ana Langer ◽  
...  
Keyword(s):  
Primary Care ◽  
Health System ◽  
Health Systems ◽  
Low Income ◽  
High Income ◽  
High Quality ◽  
Financial Barriers ◽  
Care Facilities ◽  
Health System Redesign ◽  
Maternal And Newborn

Large disparities in maternal and neonatal mortality exist between low- and high-income countries. Mothers and babies continue to die at high rates in many countries despite substantial increases in facility birth. One reason for this may be the current design of health systems in most low-income countries where, unlike in high-income countries, a substantial proportion of births occur in primary care facilities that cannot offer definitive care for complications. We argue that the current inequity in care for childbirth is a global double standard that limits progress on maternal and newborn survival. We propose that health systems need to be redesigned to shift all deliveries to hospitals or other advanced care facilities to bring care in line with global best practice. Health system redesign will require investing in high-quality hospitals with excellent midwifery and obstetric care, boosting quality of primary care clinics for antenatal, postnatal, and newborn care, decreasing access and financial barriers, and mobilizing populations to demand high-quality care. Redesign is a structural reform that is contingent on political leadership that envisions a health system designed to deliver high-quality, respectful care to all women giving birth. Getting redesign right will require focused investments, local design and adaptation, and robust evaluation.

A Comparison Study of Primary Care Utilization and Mental Health Disorder Diagnoses Among Children In and Out of Foster Care on Medicaid

2020 ◽  
Vol 59 (3) ◽  
pp. 252-258 ◽  
Author(s):  
Rachael J. Keefe ◽  
Bethanie S. Van Horne ◽  
Cary M. Cain ◽  
Katherine Budolfson ◽  
Richard Thompson ◽  
...  
Keyword(s):  
Mental Health ◽  
Primary Care ◽  
Foster Care ◽  
Health System ◽  
Mental Health Disorder ◽  
Care Utilization ◽  
Primary Care Visit ◽  
Care Services ◽  
Children In Foster Care ◽  
Primary Care Services

The purpose of this study was to compare the utilization of primary care services and presence of mental health disorder diagnoses among children in foster care to children on Medicaid not in foster care in a large health system. The data for this study were analyzed from a clinical database of a multipractice pediatric health system in Houston, Texas. The sample included more than 95 000 children covered by Medicaid who had at least one primary care visit during the 2-year study period. The results of the study demonstrated that children not in foster care had a greater number of primary care visits and the odds of having >3 visits were significantly lower for children in foster care with a mental health disorder diagnosis. Additionally, more than a quarter of children in foster care had a diagnosis of a mental health disorder, compared with 15% of children not in foster care.

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