The Complexity of Co-designing and Implementing a Transmural Care Pathway for Patients treated with Oral Anticancer Drugs: a Qualitative Study

Abstract

Background: Due to the emergence of oral anticancer drugs (OACD), changes in traditional roles and responsibilities of healthcare professionals (HCPs) in oncology and re-organization of current care processes are needed. Moreover, considering the ambulatory character of OACD, involvement of primary care HCPs seems crucial. Ten Belgian hospitals participated in the Collaborative Network to take Responsibility for Oral Anticancer Therapy (CONTACT)-project, aiming to co-design and implement a transmural care pathway for patients on OACD. This study aimed to get insight in the co-design process in these hospitals and its results. 
 Methods: In each hospital, a project team, including a project coordinator, was set up. Project teams started the co-design process from the results of an assessment of the current care process, performed from the perspective of patients and HCPs, by using questionnaires. Throughout the co-design process, project team meetings and in-between meetings in smaller groups, were held and reported by the local coordinator. 
 For this study, a qualitative content analysis was conducted using reports and care pathway documents provided by the local project coordinators. Additionally, semi-structured interviews with the coordinators were conducted to get a deeper understanding of the co-design process. 
 Results: Although hospitals were encouraged to involve representatives of primary care in the co-design process, only few hospitals invited them to participate. Even in those hospitals where they were invited, their participation strongly decreased during the process. 
 In the current practice assessment, the involvement of primary care HCPs was evaluated poorly by both patients and HCPs. In most hospitals, community pharmacists and home care nurses were not informed about the start of treatment. None of the primary care HCPs, including the general practitioner (GP), did receive necessary information about the OACD or contact details of the hospital team. Also, the therapy plan of the patient was not shared with the primary care HCPs. 
 The care pathways that were developed during the co-design process almost all mentioned that an information leaflet about the OACD and a therapy plan of the patient should be added to the report for the GP at the start of treatment. In the care pathway of half of the hospitals, it was mentioned that the same information should also be provided to the community pharmacist and home care nurse. Based on the reports, the hospital teams did not seem to take any further initiatives to elaborate transmural care. In the interviews, coordinators indicated that more extensive transmural collaboration is rather a long-term perspective; hospital teams seem to think they first need to focus on in-hospital reorganization.
 Discussion: Informing primary care HCPs, especially the GP, about treatment-initiation seemed a feasible intervention and was considered a quick win. This rather small initiative can have a large impact on care quality as it enables primary care HCPs to take up their role in the care for patients on OACD. As building transmural collaboration does only seem feasible after a thorough in-hospital reorganization, a phased approach, in which collaboration with primary care is further elaborated in a second phase, seems appropriate.