What fixes can improve cancer care quality at safety-net hospitals?

Abstract

243 Background: Safety-net hospitals are at higher risk of poor quality cancer care and vary in levels of quality performance. Types of quality problems may differ and require different interventions. We undertook this study to identify organizational factors affecting quality and assess the early findings of the innovation’s impact on hand-offs between specialists. Methods: As part of a RCT testing a web-based tracking and feedback innovation to close referral loops, new breast cancer cases are rapidly ascertained, and post-surgical medical and radiation oncologist visits are assessed. Surgeons are alerted to patients who do not show to oncology visits to stimulate action. Of 153 enrolled women (98 Intervention/ 55 Control), 4% are white. In addition, we conducted 90 key informant interviews in 9 safety-net hospitals in the NYC metropolitan area and performed a qualitative comparative analysis (QCA), a method to assess causal complexity, to identify organizational factors associated with poor quality. Results: No-shows at oncology appointments triggering surgeon feedback occurred for 5/98 (5%) new breast cancer patients. QCA revealed 6 conditions associated with poor quality-defined as underuse of needed adjuvant treatment: information sharing; follow-up; system support; patient-centered culture; flexibility and private practice. All high-performing hospitals had a patient-centered culture, strong follow-up approaches and shared information. Some of these high-quality sites had robust system support while others had creative workarounds (flexibility) or were responsive to their private practice patients. Overall, these pathways had high consistency (.88) and coverage (.72). Only hospitals with both poor follow-up and system support activated the web-based feedback. Conclusions: Safety-net hospitals with poor follow-up capabilities may benefit from an innovation designed to improve hand-offs across specialties. This trial continues to accrue; we are monitoring the innovation’s effectiveness. Clinical trial information: NCT01544374.