This study aimed to compare ITW intensity with PREM dimensions of care among cancer outpatients. The results show that cancer patients treated in outpatient clinics characterized by high ITW intensity are more likely to report positive perceptions regarding four PREMs dimensions (Prompt access to care, Person-centred response, Quality of patient-professional communication, and Continuity of care), compared to patients treated in clinics with low ITW intensity. The results thus support the hypothesis whereby higher ITW intensity within cancer care teams translates into a more positive patient perception of their care experience.
Patient-reported experience
To the best of our knowledge, and considering reviews in the field of interdisciplinary teamwork and patient-reported outcomes, our study is one of the few to demonstrate the extent to which positive patient perception of
Prompt access to care is associated with high ITW intensity within care teams [
5‐
7]. Positive patient perception of
Prompt access to care is an important anticipated effect of high ITW intensity. Indeed, access to cancer care from first symptoms to treatment is a topic of concern for researchers and policy makers [
44‐
47]. In our study,
Prompt access to care was defined as patients’ perception of their ability to reach or see an oncology professional, as required, at various times of the day and on different days of the week. Outpatients, who are by definition outside the hospital setting, must employ a number of self-management strategies to cope with their cancer symptoms and treatment. When these coping strategies fail, the patients’ unmet needs may require prompt access to care professionals [
48]. A possible explanation of the association between high ITW intensity and positive perception of
Prompt access to care is that ITW is aimed at improving care coordination by facilitating appropriate referral mechanisms to the relevant team member [
49]. If this explanation is correct, our results would suggest that high ITW intensity has the potential to break down the “silos” in the health care system, reduce the barriers between multiple health professionals located in different settings (e.g., ambulatory oncology clinic, hospital, home care), and blur the arbitrary distinction between medical and psychosocial needs. Indeed, patients’ positive perception of
Prompt access to care is an important positive effect of high ITW intensity.
Positive perception of
Quality of patient-professional communication was the second most positive effect of high ITW intensity documented in this study. Such communication is considered vital to quality patient care, particularly in oncology settings [
50,
51]. Patient-professional communication reflects the ability of a professional to listen to the patient, provide a clear response, and embrace a shared decision-making (SDM) approach. SDM is directly related to patient-professional dynamics. In the oncology field, high levels of satisfaction and confidence in treatment decisions are positively associated with SDM and are related to low levels of patient depression. These associations are independent of the patients’ preferred level of participation (passive or active) in SDM [
52]. On the one hand, patients report their symptoms and self-management activities to a team member who, in turn, provides additional information about treatment outcomes and shares the information with other team members. This information is valuable because it enables team members to tailor interventions to the individual by taking into account his or her specific characteristics and behavior patterns. On the other hand, it is well documented that poorly managed communication in the oncology field can result in unnecessary treatment and emotional distress for patients, thus negatively affecting their care experience [
51,
53,
54]. This may explain why lower ITW intensity was less strongly associated with positive perception of
Quality of patient-professional communication in our study.
The association between positive perception of
Person-centred response and high ITW intensity in the context of cancer care was another important finding. Since the Institute of Medicine’s seminal publication [
55], the patient-centred approach has been considered the hallmark of high-quality care. Over the past two decades, patient-centred care has become internationally recognized as a dimension of the broader concept of high-quality health care, and many countries are now designing and implementing strategies and programs in this regard [
56]. In a recent systematic review on cancer team effectiveness, only one study out of eleven addressed patient-centred care as an outcome indicator during active treatment. A qualitative multiple-case study completed with two interdisciplinary cancer teams from a Canadian teaching hospital reported that integrating patient values and preferences was still difficult for cancer care professionals, and patients were often expected to follow the rules established by professionals [
57]. Bilodeau et al. concluded that two conflicting models shape the organization of oncology services: patient-centred discourse and professional-centred practice [
57]. The association between high ITW intensity and positive perception of person-centred response may bring us to envision ITW as a way of accommodating the strengths of these two models, cancer care being seen as a professional service as well as a human relationship between patients and health professionals.
Our results indicate that patients receiving care in outpatient clinics with high ITW intensity are twice as likely to have positive perceptions of
Continuity of care, compared to patients in clinics with low ITW intensity. Indeed, continuity of care is not simply about seeing the same health care professional at every visit; it is about perceiving that the interdisciplinary team uses all the information at its disposal (clinical and personal) for effective care planning. Health care professionals in teams with high ITW intensity tend to share the professional responsibility of oncology treatment and follow-up, offering more holistic patient care and allowing more opportunities to diagnose cancer recurrence. High ITW intensity involves paying attention to and anticipating the potential impact of cancer and its treatment, dealing with service silos, managing consequences for the whole person, and ensuring that important aspects of care have not been overlooked by the health professionals involved [
58]. When professionals work together, attention can be directed to overcoming barriers facing patients, such as lack of knowledge of symptoms; late diagnosis and treatment due to fear; anxiety about disruption of work; child care problems; financial concerns; and unreliable transportation [
59,
60].
Contrary to the conclusions of systematic reviews on ITW [
5‐
7], we did not find an association between high ITW intensity and positive patient perception of
Results of care. One possible explanation may be that the association between ITW intensity and perceptions of
Results of care has multiple determinants, creating an indirect association. Other types of interventions, such as tumor boards focusing on therapeutic regimens, systematic symptom evaluations, and interventions by individual professionals, may act on the pathway between ITW intensity and patient-reported experience.
There was no association between high ITW intensity and positive perception of
Quality of the care environment. Perhaps patients perceive the patient-professional-team relationship as having more importance than
Quality of the care environment. Another explanation may be that basic amenities and professional courtesy are not directly related to ITW intensity. Some studies suggest that the responsibility to create a healing environment belongs all those working in a cancer setting, regardless of ITW intensity, and that this responsibility is embedded in complex relationships between professional practices, setting, and care providing processes [
61].
Strengths and limitations of the study
A conceptual framework was used to ensure methodological transparency. Our measurements of interdisciplinary teamwork focused on both team structure and process items that characterize teams with high or low ITW intensity. We used the available validated instruments, which were cancer-adapted and had good reliability scales overall. No validated tool was available to evaluate ITW intensity in teams such as those in Quebec that include a diversity of professionals [
4,
20,
21]. The general view in the literature is that the traditional criteria for scientific validity (e.g., internal consistency) do not by themselves guarantee usefulness to practitioners. Considering our pragmatic stance with the ITW tool, our work concentrated on content and pragmatic validity [
62]. Pragmatic validity of knowledge can be judged by the extent to which intended consequences can be achieved by using particular instruments.
We thus carefully developed a measurement tool specific to oncology care. Although the tool is still under development, we used recognized procedures to ensure content validity evaluation [
63]. The tool could be used in its current form to measure ITW intensities of other cancer care teams that are similar in size and include a diversity of professionals focusing on comprehensive patient-centred cancer care. However, it should not be used for interdisciplinary teams that are solely oriented toward medical treatments (e.g., cancer conferences or tumor boards). Potential misclassification of ITW intensity was mitigated by using information from the administrative database of the Ministry of Health and Social Services and interviews with front-line managers from each participating clinic [
64].
Certain limitations may also be related to the PREMs scale. The tool used to measure perception of
Results of care and
Quality of the care environment was derived from the primary care sector. It is possible that it was not sufficiently sensitive to fully capture the effects of high ITW intensity, since all cancer teams work together to some extent. Finally, reliability (alpha = 0.64) of the
Quality of the care environment scale (alpha = 0.64) was the lowest of all the scales used in the study, despite the fact that it was a cancer-adapted validated scale [
26]. This may have reduced the ability to identify significant associations. Overall, it is difficult to compare our results with previous studies in the oncology setting [
5,
40,
65] due to significant differences in study design, the conceptualization and measurement of interdisciplinary teamwork, and the dimensions of patient-reported differences. Nevertheless, our study contributes to research aiming to provide evidence for the effects of ITW.
Whereas
ex post facto quasi-experimental design is not optimal [
19], it is important to realize that no other study design was possible, since ITW is already implemented to varying degrees in all cancer teams in Quebec [
66]. Given the high response rate among patients, the diversity of organizational characteristics of the clinics that were included, and our careful assessment of ITW intensity, the results of this study could be generalized to patients treated and followed up in similar settings [
67]. Finally, considering the characteristics of our sample, and because access to medical services is universal in Quebec, we feel cautious about generalizing our results to other health care systems. Nevertheless, our study has strong internal validity due to the robustness of its methodology.