Optimizing clinical and organizational practice in cancer survivor transitions between specialized oncology and primary care teams: a realist evaluation of multiple case studies

The goal is to develop, analyze and implement a demonstration project and evaluate the outcomes of a Risk-based Coordinated Cancer Care Model (referred to hereafter by the acronym RbCCCM) that focuses on cancer survivors’ transitions between specialized oncology teams and primary care teams. This goal is formulated according to the Medical Research Council’s stages of development for complex interventions [28‐30], and is specifically adapted to people with chronic diseases [31]. The study will address the following questions:

Answering these questions involves mobilizing the components of our theoretical framework and taking a participatory approach, involving researchers/front-line actors/patients, inspired by intervention research [32‐34]. Our working hypothesis is that a RbCCCM involving specialized cancer care teams and primary care teams will have a positive effect on professional practice and, in the end, on the survivors’ experience of transitions between teams.

The RbCCCM is a novel intervention with multiple components: professional, organizational, client-based (patients and families), governance (Table 1). To address the fragmentation of care, the RbCCCM relies on activities that promote coordinated clinical and organizational practices and on the behaviour of survivors during the transition from oncology care to primary care [35, 36]. The RbCCCM incorporates consideration of cancer-related risks that may combine with multimorbidity in certain patients [31].

The intervention involves four interrelated steps: I) development of a RbCCCM based on evidence around survivorship care models and an environmental scan of the Québec context; II) implementation of a demonstration project; III) measurement of the model’s effects on professionals and survivors; and IV) evaluation of conditions required for the RbCCCM to produce these effects.

The analytical framework (Fig. 1) combines theoretical work and empirical evidence from Tremblay et al.’s previous research [37, 38]. It is inspired by aspects of actor-network theory (ANT), which, very briefly, holds that translating a novel intervention into practice depends on the ability of multiple actors — with diverse interests, needs and objectives that are often in competition — to work together towards a common goal [39‐41]. The construction of this network to support an intervention (the RbCCCM in our case) proceeds in four key stages along the path from idea to practice: contextualization (identification of actors/resources and the play of influence at different levels); problem definition (discussion/decision-making processes to clarify the problem and its solution, determine mechanisms that need to be activated and the initial intervention theory); mobilization, whereby actors become interested in the innovation (interessement), assume roles (enrolment) and commit (commitment) to achieving the anticipated outcomes of the innovation and monitoring processes and effects [42]. To render the ANT more concrete in operational terms, the framework includes principles of realist evaluation [43‐46]. Realist evaluation is an approach that brings together: 1) the multi-level context and its influence on professional and organizational practice as well as the experience of people living with cancer (contextualization (C)) [47]; 2) development of a common definition of the problem and identification of the novel intervention’s components, leading to the development of an initial theory of RbCCCM (problem definition); 3) activation of mechanisms (M) in terms of people’s interessement, enrolment and commitment to the RbCCCM (mobilisation); and 4) monitoring of anticipated or unanticipated outcomes (O) in professional and organizational practice and the experience of cancer survivors (monitoring). The successful translation of the intervention (RbCCCM) into practice would involve the achievement of positive effects without producing unanticipated negative effects. The arrows in the figure illustrate that the translation process is not necessarily linear. For more details see Additional file 1.

The design for analyzing the implementation (Step II) and evaluation of outcomes (Step III) is a multiple case study [54] based on qualitative and quantitative data [55]. The design is appropriate to understanding a contemporary phenomenon (the RbCCCM) as it manifests in the real world where it may be influenced by multiple changing and interdependent factors and contextual challenges. A case is defined as the cancer care trajectory in order to understand how the RbCCCM mobilizes members of specialized cancer care teams and primary care teams during transitions.

The selection of cases is based on theory [54] to represent real-world differences [56] in terms of geographic location (the territorial expanse served; rural/semi-urban/urban areas), mission (academic or not), the size and diversity of care teams and their interest in being involved in the RbCCCM demonstration project. Units of analysis are the hospital-based cancer care teams and the FMGs of two Integrated Health and Social Service Centres (3/11 FMGs + one hospital in Saguenay-Lac-Saint-Jean (Case 1); 3/31 FMGs + one hospital in the Montérégie (Case 2). The selection of cases is also influenced by feasibility and our knowledge of these establishments gained through their participation in prior research we conducted on cancer care [8, 37, 38, 57‐63], on primary care [64, 65], as well as on organizational factors that influence the care experience of people having received a cancer diagnosis [38].

Case 1 is an academic health centre that has deployed, since 2010, an intervention in FMGs aimed at improving care coordination for people with chronic diseases (other than cancer) through nurse case managers and group sessions to support self-management [64, 65]. In this case, the RbCCCM might be integrated into these existing practices, with cancer treated as a chronic disease [13]. Case 2 has, since 2001, deployed efforts in specialized cancer care (nurse navigators, implementation of a cancer care network, development of an integrated centre, introduction of the clinician advisor role) [37, 38, 60, 63, 66, 67]. The two cases offer possibilities for analyzing the RbCCCM and better understanding variations in implementation and outcomes. The realist approach is employed for its pragmatic and participatory principles that help to discover what works (and what doesn’t), how it works, for whom, and under what conditions. This approach is suited to analysis of complex interventions [48].

In line with the Knowledge to Practice framework [91], our knowledge exchange strategy considers the particular needs of each knowledge user. The research approach therefore involves key informants and users in the development of the RbCCCM intervention. This strategy enables the targeting of significant evidence to potential users and the adaptation of the intervention to local contexts (clinical tools, referral criteria). As well, the inclusion of knowledge users and partnership with a cancer survivor on the research team enable the identification of facilitators and impediments (e.g. lack of knowledge about survivorship care) to the implementation of the RbCCCM. Effective strategies to overcome these obstacles may then be used as educational interventions (accredited continuing medical education) or as interventions led by patients (e.g. patient awareness of the RbCCCM leads them to request a survivorship plan from their specialist). To promote and deepen exchanges, knowledge users will be informed on a regular basis about progress on the project (e.g. newsletter, agenda item on monthly clinical meetings). As well, the research team will organise (1×/year) a half-day knowledge exchange symposium on themes related to the RbCCCM (presentation of scoping review, preliminary results).

Components of the Knowledge to Practice framework are the cornerstone of our integrated knowledge transfer (IKT) plan [91] and are suitable for the study of innovative interventions. This framework defines knowledge uptake as a dynamic and recursive process that involves the synthesis, dissemination, exchange and uptake of knowledge with a view to improving care and strengthening the health system. This process takes place within a network of complex interactions between researchers and knowledge users that vary in intensity, complexity and commitment depending on the nature of the research and its results, as well as the particular needs of each knowledge user. It is therefore consistent with interventional research. The framework has two central components. The first draws on the notion of the funnel, where the creation of knowledge involves its progressive refinement to facilitate adoption by actors in the field. The second represents the active part of the process as a cycle leading to the implementation or application of research findings. This second component involves seven stages that may be sequential or occur in feedback loops: 1) problem identification, 2) adaptation of knowledge to local context, 3) assessment of barriers to knowledge use in that context, 4) selection, adaptation and implementation of interventions, 5) monitoring of knowledge use, 6) evaluation of results, and 7) maintenance of knowledge use. The framework is perfectly aligned with the analytical framework developed in this project (Fig. 1) and will guide us towards the interventional research goals.

Potential difficulties in this project are: 1) the engagement of professionals and their willingness to collaborate; 2) recruitment of patients; 3) the distance separating the two cases; 4) the large scope of the project. The following strategies will be adopted to reduce attendant risks: first, we have secured the participation of research nurses, remunerated by the project and recognized in each of the case settings for their clinical leadership and coaching abilities [92]. They will be able to quickly identify problems that arise with the implementation of the RbCCCM, work with the research team to find solutions suitable to the local context, and counsel team members on complex cases. Second, institutional leadership support for the project creates winning conditions. Québec institutions must periodically design and evaluate their cancer action plans, and care and service continuity is a priority in these plans. Finally, the presence of the RbCCCM will be seen by teams as a useful and supportive project.

The study will enable us to develop a Risk-based coordinated cancer care model (RbCCCM), to analyze the implementation of a demonstration project, and to evaluate the outcomes of the RbCCCM. It will allow us to test the RbCCCM in various practice communities across the health system. Anticipated results will: 1) identify factors that facilitate or impede a RbCCCM, 2) evaluate how the model is translated into clinical and organizational practice, 3) evaluate outcomes in professionals and patients, and 4) identify contexts and mechanisms that create favourable and unfavourable conditions for the production of RbCCCM outcomes. This will provide essential information for decision-makers and managers about the roles and responsibilities assumed by cancer and primary care teams in the provision of care and at transition points along the cancer care continuum. In addition, the project will increase awareness among a broad range of stakeholders (policy-makers, managers, professionals, services users) of factors that help to activate promising mechanisms involved in a coordinated model of cancer care.