Introduction
Design
Study design
The implementation strategies
Strategy elements | Directed to |
---|---|
A flyer to educate, activate, and remind patients. With information on PA and PCRPs and where information is available to guide patients’ own survivorship plans | Patients |
An interactive website for education and activation of patients, with information on • Distress Thermometer (DT) • physical oncologic rehabilitation • PCRPs • PCR guidelines • web-based exercises • care provider search • quality assurance | Patients |
Strategy elements | Directed to |
---|---|
A flyer to educate, activate, and remind patients, with information on PA and PCRPs and where information is available to guide patients’ own survivorship plans | Patients |
An interactive website for education and activation of patients. With information on • Distress Thermometer (DT) • physical oncologic rehabilitation • PCRPs • PCR guidelines • web-based exercises • care provider search • quality assurance | Patients |
An interactive website for education of the healthcare professionals, with information on • Distress Thermometer (DT) • physical oncologic rehabilitation • PCRPs • PCR guidelines • web-based exercises • care provider search • quality assurance | Professionals |
A pocket-card for healthcare professionals with • descriptions of care pathways • important contact details for referral to PCRPs • the web-address of the interactive website • contact details of the contact person in the care process for patients and professionals for the PCR guidelines process. | Professionals |
Outreach visits regarding PCRPs to educate healthcare professionals on regional possibilities of referral and importance of communication with patients. | Professionals |
Optimized description of care pathways on PCR-care • when offering PCRP in a care pathway • responsibility per person what and when | Organization |
Improved hospital protocols on PCRP | Organization |
Establishing a permanent contact person in the care process for patients and professionals for the PCR guidelines process. | Organization |
Study population and recruitment
Data collection
Outcome measures of effectiveness
Primary outcome measure
Secondary outcome measures: the indicators
Secondary outcome measures: patient reported outcomes (PROs)
Outcome measures of feasibility
Characteristics of patients and cancer center
Power calculation
Data analysis
Results
Patient and cancer center characteristics
PD strategy | MF strategy | p** | |||
---|---|---|---|---|---|
Before-measurement | After-measurement | Before-measurement | After-measurement | ||
No. of patients | 353 | 261 | 320 | 392 | |
Age, years | Mean (SD) | Mean (SD) | Mean (SD) | Mean (SD) | 0.0013 |
68.4 (10.0) | 67.4 (10.3) | 67.3 (11.7) | 65.1 (12.8) | ||
No. (%*) | No. (%*) | No. (%*) | No. (%*) | ||
Sex | <0.0001 | ||||
Female | 109 (31.3) | 73 (28.5) | 181 (57.8) | 266 (68.6) | |
Male | 239 (68.7) | 183 (71.5) | 132 (42.2) | 122 (31.4) | |
Dutch | 0.6048 | ||||
Yes | 321 (92.7) | 229 (89.8) | 285 (91.9) | 351 (92.1) | |
No | 25 (7.2) | 26 (10.2) | 25 (8.1) | 30 (7.9) | |
Primary tumor type | <0.0001 | ||||
Female organs | 45 (12.8) | 37 (14.2) | 115 (35.9) | 223 (56.9) | |
Urogenital organs | 205 (58.1) | 154 (59.0) | 31 (9.7) | 28 (7.1) | |
Gastrointestinal | 103 (29.2) | 70 (26.8) | 174 (54.4) | 141 (36.0) | |
Treatment | |||||
Surgery | 269 (76.2) | 187 (71.7) | 289 (90.3) | 336 (85.9) | <0.0001 |
Chemotherapy | 104 (29.5) | 76 (29.1) | 118 (36.9) | 148 (37.8) | 0.0220 |
Radiotherapy | 107 (30.3) | 69 (26.4) | 80 (25.0) | 99 (25.3) | 0.3556 |
Hormonal therapy | 48 (13.6) | 26 (10.0) | 15 (4.7) | 19 (4.9) | <0.0001 |
Other | 27 (7.7) | 24 (9.2) | 11 (3.4) | 16 (4.1) | 0.0048 |
No of treatments | 0.0141 | ||||
<2 | 199 (56.4) | 164 (62.8) | 162 (50.6) | 204 (52.0) | |
≥2 | 154 (43.6) | 97 (37.2) | 158 (49.4) | 188 (48.0) | |
No of comorbidities | 0.2415 | ||||
<2 | 244 (69.1) | 195 (74.7) | 224 (70.0) | 264 (67.4) | |
≥2 | 109 (30.9) | 66 (25.3) | 96 (30.0) | 128 (32.7) | |
Weight after treatment | 0.1167 | ||||
Increase | 118 (34.3) | 66 (25.8) | 110 (35.7) | 140 (36.9) | |
Stable | 182 (52.9) | 146 (57.3) | 154 (50.0) | 189 (49.9) | |
Decrease | 44 (12.8) | 43 (16.9) | 44 (14.3) | 50 (13.2) | |
Living circumstances | 0.4024 | ||||
Alone | 66 (18.9) | 47 (18.2) | 72 (22.5) | 86 (22.3) | |
Cohabiting | 283 (81.1) | 212 (81.9) | 248 (77.5) | 300 (77.7) | |
Education level | 0.0482 | ||||
Low | 131 (37.4) | 79 (30.7) | 127 (39.9) | 139 (36.3) | |
Middle | 125 (35.7) | 96 (37.4) | 125 (39.3) | 155 (40.5) | |
High | 94 (26.9) | 82 (31.9) | 66 (20.8) | 89 (23.2) | |
Employment status | 0.0731 | ||||
Working | 70 (20.5) | 61 (23.7) | 73 (23.5) | 110 (28.7) | |
Nonworking | 272 (79.5) | 196 (76.3) | 238 (76.5) | 273 (71.3) | |
Type of cancer center | <0.0001 | ||||
Categorical | 0 (0.0) | 0 (0.0) | 55 (17.2) | 126 (32.1) | |
University | 156 (44.2) | 119 (45.6) | 49 (15.3) | 89 (22.7) | |
Teaching | 55 (15.6) | 35 (13.4) | 111 (34.7) | 107 (27.3) | |
Nonteaching | 142 (40.2) | 107 (41.0) | 105 (32.8) | 70 (17.9) |
Center 1 | Center 2 | Center 3 | Center 4 | Center 5 | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Type of center | ||||||||||
Categorical | ||||||||||
University | √ | |||||||||
Teaching | √ | |||||||||
Nonteaching | √ | √ | √ | |||||||
MORB available | ||||||||||
Before | After | Before | After | Before | After | Before | After | Before | After | |
Screening DT | √ | √ | √ | √ | √ | √ | √ | √ | ||
PCRP/physiotherapy | ||||||||||
Internal PCRP | √ | |||||||||
External PCRP | √ | √ | √ | √ | ||||||
Physiotherapy | √ | √ | √ | √ |
Center 6 | Center 7 | Center 8 | Center 9 | |||||
---|---|---|---|---|---|---|---|---|
Type of center | ||||||||
Categorical | √ | |||||||
University | √ | |||||||
Teaching | √ | |||||||
Nonteaching | √ | |||||||
MORB available | √ | |||||||
Before | After | Before | After | Before | After | Before | After | |
Screening DT | √ | √ | √ | √ | √ | √ | ||
PCRP/physiotherapy | ||||||||
Internal PCRP | √ | √ | √ | √ | ||||
External PCRP | √ | √ | ||||||
Physiotherapy | √ | √ | √ | √ |
Effectiveness of implementation strategies
Before | After | Delta | Change uncorrected | Change corrected | |||
---|---|---|---|---|---|---|---|
No (%*) | No (%*) | OR | p | OR** | p | ||
Screening with the DT | |||||||
Yes | 120 (34.2) | 112 (43.1) | 8.9 | 1.6349 | 0.0060 | 1.6706 | 0.0072 |
No | 231 (65.8) | 148 (56.9) | |||||
Information provision concerning PA and PCRPs | |||||||
Yes | 129 (37.5) | 109 (42.8) | 5.3 | 1.2013 | 0.2923 | 1.2663 | 0.1962 |
No | 215 (62.5) | 146 (57.3) | |||||
Advice to take part in PA and PCRPs | |||||||
Yes | 176 (50.3) | 142 (54.6) | 4.3 | 1.1833 | 0.3150 | 1.3147 | 0.1370 |
No | 174 (49.7) | 118 (45.4) | |||||
Referral to PCRPs | |||||||
Yes | 39 (11.2) | 24 (9.3) | −1.9 | 0.8115 | 0.4463 | 0.8148 | 0.4975 |
No | 310 (88.8) | 235 (90.7) |
Before | After | Delta | Change uncorrected | Change corrected | |||
---|---|---|---|---|---|---|---|
No (%*) | No (%*) | OR | p | OR** | p | ||
Participation in PCRPs | |||||||
Yes | 70 (20.1) | 53 (20.7) | 0.6 | 1.0246 | 0.9069 | 1.0653 | 0.7783 |
No | 278 (79.9) | 203 (79.3) | |||||
PAU | |||||||
Yes | 140 (40.1) | 97 (37.7) | −2.4 | 0.9050 | 0.5544 | 0.9381 | 0.7250 |
No | 209 (59.9) | 160 (62.3) | |||||
Mean (SD) | Mean (SD) | Delta | Change | p | Change | p | |
EORTC QLQ-C30 | |||||||
Mean summary score | 40.6 (5.6) | 40.6 (5.7) | 0.0 | 0.09838 | 0.8344 | 0.3144 | 0.5052 |
Global health status/QoL | 77.1 (18.1) | 78.4 (18.2) | 1.3 | 1.1599 | 0.4466 | 1.1688 | 0.4233 |
Physical function | 85.3 (16.5) | 85.6 (17.7) | 0.3 | 0.1142 | 0.9356 | 0.07302 | 0.9547 |
MFI-20 score | |||||||
Mean general fatigue | 9.3 (4.4) | 9.7 (4.6) | .4 | 0.4881 | 0.1908 | 0.5177 | 0.1525 |
Mean physical fatigue | 9.2 (4.2) | 9.4 (4.5) | .2 | 0.3205 | 0.3699 | 0.3726 | 0.2875 |
PAM-13 | |||||||
Mean total score | 56.8 (12.9) | 55.6 (12.6) | −1.2 | −1.1979 | 0.2981 | −1.6979 | 0.1615 |
Before | After | Delta | Change uncorrected | Change corrected | |||
---|---|---|---|---|---|---|---|
No (%*) | No (%*) | OR | p | OR** | p | ||
Screening with the DT | |||||||
Yes | 131 (41.5) | 220 (56.1) | 14.6 | 1.5713 | 0.0052 | 1.7098 | 0.0028 |
No | 185 (58.5) | 172 (43.9) | |||||
Information provision concerning PA and PCRPs | |||||||
Yes | 122 (39.4) | 162 (42.6) | 3.2 | 1.1839 | 0.3015 | 1.2896 | 0.1398 |
No | 188 (60.7) | 218 (57.4) | |||||
Advice to take part in PA and PCRPs | |||||||
Yes | 164 (51.9) | 220 (56.9) | 5.0 | 1.1785 | 0.2939 | 1.1284 | 0.4871 |
No | 152 (48.1) | 167 (43.2) | |||||
Referral to PCRPs | |||||||
Yes | 45 (14.3) | 51 (13.4) | −0.9 | 0.9171 | 0.7070 | 1.0093 | 0.9707 |
No | 269 (85.7) | 329 (86.6) |
Before | After | Delta | Change uncorrected | Change corrected | |||
---|---|---|---|---|---|---|---|
No (%*) | No (%*) | OR | p | OR** | p | ||
Participation in PCRPs | |||||||
Yes | 77 (24.6) | 75 (19.8) | −4.8 | 0.7216 | 0.0864 | 0.7137 | 0.0990 |
No | 236 (75.4) | 303 (80.2) | |||||
PAU | |||||||
Yes | 140 (44.6) | 165 (43.0) | −1.6 | 0.8860 | 0.4471 | 0.9896 | 0.9363 |
No | 174 (55.4) | 219 (57.0) | |||||
Mean (SD) | Mean (SD) | Delta | Change | p | Change | p | |
EORTC QLQ-C30 | |||||||
Mean summary score | 41.1 (5.1) | 41.4 (6.1) | 0.3 | 0.1552 | 0.7282 | 0.08138 | 0.8585 |
Global health status/QoL | 78.0 (17.7) | 77.3 (17.6) | 0.7 | 0.5088 | 0.7074 | 0.4964 | 0.7004 |
Physical function | 81.4 (19.0) | 82.7 (17.7) | 1.3 | 1.8064 | 0.2009 | 1.6891 | 0.2008 |
MFI-20 score | |||||||
Mean general fatigue | 9.9 (4.5) | 10.3 (4.6) | 0.4 | −0.0403 | 0.9085 | −0.0395 | 0.9070 |
Mean physical fatigue | 9.6 (4.5) | 10.0 (4.4) | 0.4 | 0.1448 | 0.6769 | 0.2429 | 0.4684 |
PAM-13 | |||||||
Mean total score | 55.9 (13.9) | 54.7 (13.1) | −1.2 | −1.1699 | 0.2515 | −1.0151 | 0.3378 |
Delta | Difference uncorrected | Difference corrected | |||
---|---|---|---|---|---|
No (%*) | OR ratio | p | OR ratio** | p | |
Screening with the DT | |||||
5.7 | 1.0586 | 0.8130 | 1.0331 | 0.8995 | |
Information provision concerning PA and PCRPs | |||||
−2.1 | 0.9923 | 0.9741 | 0.9918 | 0.9734 | |
Advice to take part in PA and PCRPs | |||||
0.7 | 0.9913 | 0.9695 | 1.1085 | 0.6804 | |
Referral to PCRPs | |||||
1.0 | 0.8907 | 0.7497 | 0.8236 | 0.6215 |
Delta | Difference uncorrected | Difference corrected | |||
---|---|---|---|---|---|
No (%*) | OR ratio | p | OR ratio** | p | |
Participation in PCRPs | |||||
−4.2 | 1.3939 | 0.2382 | 1.4133 | 0.2506 | |
PAU | |||||
0.8 | 1.0072 | 0.9756 | 1.0128 | 0.9583 | |
Mean | Difference | p | Difference | p | |
EORTC QLQ-C30 | |||||
Mean summary score | 0.3 | −0.06646 | 0.9187 | 0.2656 | 0.6841 |
Global health status/QoL | −0.6 | 0.6913 | 0.7340 | 0.6273 | 0.7449 |
Physical function | 1.0 | −1.6934 | 0.3999 | −1.3749 | 0.4616 |
MFI-20 score | |||||
Mean general fatigue | 0.0 | 0.5183 | 0.3186 | 0.5723 | 0.2449 |
Mean physical fatigue | 0.2 | 0.1675 | 0.7406 | 0.2097 | 0.6657 |
PAM-13 | |||||
Mean total score | 0.0 | −0.0218 | 0.9886 | −1.1235 | 0.4843 |
Feasibility
Total | |
---|---|
Flyer (n=244) | |
Median rate score | 8 out of 10 |
No (%*) | |
Remembered receiving flyer | 137 (56) |
Read flyer after receiving it | 112 (82) |
Agreed clear lay-out and content | 98 (88) |
Agreed flyer stimulates discussion of PA with their healthcare professionals | 68 (61) |
Website (n=624) | |
Median rate score | 7 out of 10 |
No (%*) | |
Used website | 180 (29) |
Agreed clear lay-out and content | 144 (73) |
Agreed website stimulates discussion of PA with their healthcare professionals | 131 (75) |
Reasons given for not using the website were no internet or computer (skills), patient already performed enough PA, preference for personal contact instead of written information or information via ICT systems, sufficient knowledge already about PA during and after cancer, and unaware of existence of website. |
Total | PD strategy | MF strategy | |
---|---|---|---|
No (%*) | No (%*) | No (%*) | |
Organization (N=632) | |||
Could talk about cancer rehabilitation | |||
Yes | 550 (90) | 216 (88) | 334 (92) |
No | 59 (10) | 30 (12) | 29 (8) |
Contact person available | |||
Yes | 442 (71) | 161 (66) | 281 (75) |
No | 177 (29) | 84 (34) | 93 (25) |
Contact person easily reachable | |||
Yes | 424 (83) | 159 (82) | 265 (84) |
No | 85 (17) | 36 (18) | 49 (16) |
GP involved | |||
Yes | 450 (71) | 164 (65) | 286 (76) |
No | 182 (29) | 89 (35) | 93 (24) |
GP informed | |||
Yes | 531 (87) | 201 (82) | 330 (90) |
No | 80 (13) | 43 (18) | 37 (10) |
Reasons given for no referral or PCRP participation were insufficient insurance coverage and the ensuing costs of joining a PA program, waiting lists because of lack of capacity, referral offered at inconvenient times in the treatment process, nontailored PCRPs, patient already performed enough PA, coordination of cancer treatment in cancer treatment facility that does not participate in this study, and negative advice of healthcare professionals. |