Improve Care Delivery Research Articles

How Safe Is Cancer Care?

Cancer Morbidity, Mortality, and Improvement Rounds is a series of articles intended to explore the unique safety risks experienced by oncology patients through the lens of quality improvement, systems and human factors engineering, and cognitive psychology. For purposes of clarity, each case focuses on a single theme, although, as is true for all medical incidents, there are almost always multiple, overlapping, contributing factors. The quality improvement paradigm used here, which focuses on root cause analyses and opportunities to improve care delivery systems, was previously outlined in this journal.

Design, development, and evaluation of a registry system for hyperbaric oxygen therapy: A methodological study.

Background and AimsHyperbaric oxygen therapy (HBOT), utilizes 100% oxygen at pressures greater than sea‐level atmospheric pressure, for the treatment of conditions in which the tissues starve for oxygen. The Undersea and Hyperbaric Medical Society (UHMS) has granted HBOT approval for the treatment of various conditions. On the other hand, applying informatics registry systems can improve care delivery, ameliorate outcomes, and reduce the costs and medical errors for the patients receiving HBOT treatment. Therefore, we aimed to design, develop, and evaluate a registry system for patients undergoing HBOT.MethodsIn the first phase, the conceptual and logical models were designed after conducting symposiums with experts and having other experts review the models. In the second phase, the system was developed on the web using ASP.NET and C# programming languages frameworks. The last phase involved Nielsen's heuristic evaluation method for the system's usability. Five experts evaluated the system, including three health information management specialists and two medical informatics specialists.ResultsThe hyperbaric patient information registry system (HPIRS) interacts with three types of users—a specialist physician, a nurse, and a system administrator. A scenario for each predefined activity was designed, and all the information was stored in the SQL servers. The five experts independently found 152 issues, of which 84 were duplicates. The 68 distinct issues of the system were then resolved.ConclusionsThe design and development of such registry systems can make data available and stored carefully to improve clinical care and medical research and decrease costs and errors. These registries can provide the healthcare systems with E‐health applications, improved data management, more secure data transfer, and support for statistical reporting. The implemented heuristic evaluation method can also provide a low‐cost and readily available system to fix the issues of the designed systems.

Creating a Robust Community of Practice as a Foundation for the Successful Development of a Pediatric Neurocritical Care Program

BackgroundThere has been a growing impetus for developing pediatric neurocritical care (PNCC) programs to improve care delivery for children with critical neurological conditions. We sought to develop a unique PNCC program using the concept of Community of Practice (CoP). MethodsThis is a process improvement project in an academic Children's Hospital. Using CoP framework (domain, community, practice), we created a domain of PNCC with a stated vision and formal organizational structure, a core community of intensivists and neurologists interested in PNCC, and a standardized practice approach by establishing core competencies for PNCC and implementing practice guidelines. ResultsWe evaluated the program through the Four-Frame Model of Organizational Theory and Behavior (structural, human resource, political, symbolic) and by the Neurocritical Care Society's (NCS’s) standards for a Level I Neurocritical Care Unit (Neuro-ICU). Structural frame included opening a pediatric Neuro-ICU, identifying PNCC leaders across specialties, and developing a multidisciplinary care delivery model. Human resource frame included forming physician and nurse groups with a primary role in PNCC and ongoing education through workshops, lecture series, and certification. Politically, program implementation was tailored to each department gaining institution-wide support for program initiatives. Symbolically, the PNCC program highlighted the vision to advance knowledge and best practices. Our program met 232 of 252 (92%) proposed NCS standards. ConclusionsThe CoP as the foundation for program development has enabled us to achieve the majority of standards proposed by NCS for a Level I Neuro-ICU. The generalizability of these frameworks may facilitate the development of a PNCC program for other institutions.

TOGETHER Care: PatienT-tailOred GynEcologic Oncology posT discHargE caRe (290)

TOGETHER Care: PatienT-tailOred GynEcologic Oncology posT discHargE caRe (290)

Identifying Priorities to Improve the System of Care for Children With Complex Health Needs in North Carolina: Process and Outcomes of Systematic Stakeholder Engagement.

Children with complex health needs (CCHN) have both medical (eg, chronic conditions) and health-related social needs (eg, potentially adverse social determinants of health) that require ongoing health care and support from multiple community service providers. National standards developed for populations defined by health needs (CYSHCN) provide a framework for stakeholders to plan system-level improvements in care delivery for CCHN, but improvement efforts should reflect the priorities of their families and providers. This article describes a process of prioritizing system-level efforts to improve the health and well-being of CCHN and families in North Carolina (NC), using systematic stakeholder engagement and modified Delphi expert ratings. We surveyed stakeholders with experience caring for CCHN using an open-ended, 3-item instrument to identify opportunities to improve systems of care. Using directed qualitative content analysis, we synthesized responses into a master list of potential improvement topics. Using a modified Delphi approach, a 16-member advisory committee rated all topics for importance and urgency, on 9-point Likert scales over 2 rounds; then ratings for each topic were ranked (low, medium, high) to establish relative priority. Forty seven individuals from 31 counties around NC provided survey responses, yielding 59 improvement topics in 10 domains. Through the modified Delphi method process, 21 topics (36%) received the highest rankings, largely representing access to community- and home-based services, equity, and enhancement of the pediatric workforce. Priorities identified by stakeholders will inform advocacy, policy, and improvement efforts. Next steps for the coalition include developing improvement projects to implement stakeholder-recommended actions for the highest-priority topics.

Developing National Standardized Performance Measures for School-Based Health Centers: The National Quality Initiative.

Despite extensive literature on school-based health center (SBHC) characteristics and outcomes, their quality of care has not been examined nationally. Standardized quality metrics can inform health care delivery and improvement. SBHC national performance measures (NPMs) were developed by reviewing measures from national child health quality initiatives and engaging stakeholders in a consensus-building process. NPMs were pilot-tested with 73 SBHCs and SBHCs nationally subsequently reported data. Five NPMs were selected including the percentage of clients annually who received at least one: (1) well-child visit, whether administered in the SBHC or elsewhere; (2) risk assessment; (3) body mass index screen with nutrition and physical activity counseling; and, if age-appropriate, (4) depression screening with follow-up treatment plan; and (5) chlamydia screening among sexually active clients. SBHCs experienced challenges with reporting during pilot-testing, particularly related to extracting data from electronic health records, and identified strategies to address challenges. Approximately 20% of SBHCs nationally voluntarily reported data during the initial year. Standardized performance measures can help SBHCs monitor and improve care delivery and demonstrate effectiveness compared to other child health delivery systems. Ongoing data collection will help examine whether measure adoption drives quality improvement for SBHCs nationwide.

Improving the management of chronic pain, opioid use, and opioid use disorder in older adults: study protocol for I-COPE study

BackgroundOlder adults with chronic pain, opioid use, and opioid use disorder (OUD) present complex management decisions in primary care. Clinical tools are needed to improve care delivery. This study protocol describes the planned implementation and evaluation of I-COPE (Improving Chicago Older Adult Opioid and Pain Management through Patient-centered Clinical Decision Support and Project ECHO®) to improve care for this population.MethodsThis study uses a pragmatic, expanding cohort stepped-wedge design to assess the outcomes. The study will be implemented in 35 clinical sites across metropolitan Chicago for patients aged ≥ 65 with chronic pain, opioid use, or OUD who receive primary care at one of the clinics. I-COPE includes the integration of patient-reported data on symptoms and preferences, clinical decision support tools, and a shared decision-making tool into routine primary care for more effective management of chronic pain, opioid prescribing, and OUD in older adults. Primary care providers will be trained through web-based videos and an optional Project ECHO® course, entitled “Pain Management and OUD in Older Adults.” The RE-AIM framework will be used to assess the I-COPE implementation. Effectiveness outcomes will include an increased variety of recommended pain treatments, decreased prescriptions of higher-risk pain treatments, and decreased patient pain scores. All outcomes will be evaluated 6 and 12 months after implementation. PCPs participating in Project ECHO® will be evaluated on changes in knowledge, attitudes, and self-efficacy using pre- and post-course surveys.DiscussionThis study will provide evidence about the effectiveness of collecting patient-reported data on symptoms and treatment preferences and providing clinical decision support and shared decision-making tools to improve management for older adults with chronic pain, opioid use, and OUD.Trial registrationClinicalTrials.gov NCT04878562.

Effect of Smartphone App–Based Education on Clinician Prescribing Habits in a Learning Health Care System

Effective methods for engaging clinicians in continuing education for learning-based practice improvement remain unknown. To determine whether a smartphone-based app using spaced education with retrieval practice is an effective method to increase evidence-based practice. A prospective, unblinded, single-center, crossover randomized clinical trial was conducted at a single academic medical center from January 6 to April 24, 2020. Vanderbilt University Medical Center clinicians prescribing intravenous fluids were invited to participate in this study. All clinicians received two 4-week education modules: 1 on prescribing intravenous fluids and 1 on prescribing opioid and nonopioid medications (counterbalancing measure), over a 12-week period. The order of delivery was randomized 1:1 such that 1 group received the fluid management module first, followed by the pain management module after a 4-week break, and the other group received the pain management module first, followed by the fluid management module after a 4-week break. The primary outcome was evidence-based clinician prescribing behavior concerning intravenous fluids in the inpatient setting and pain medication prescribing on discharge from the hospital. A total of 354 participants were enrolled and randomized, with 177 in group 1 (fluid then pain management education) and 177 in group 2 (pain management then fluid education). During the overall study period, 16 868 questions were sent to 349 learners, with 11 783 (70.0%) being opened: 10 885 (92.4%) of those opened were answered and 7175 (65.9%) of those answered were answered correctly. The differences between groups changed significantly over time, indicated by the significant interaction between educational intervention and time (P = .002). Briefly, at baseline evidence-concordant IV fluid ordered 7.2% less frequently in group 1 than group 2 (95% CI, -19.2% to 4.9%). This was reversed after training at 4% higher (95% CI, -8.2% to 16.0%) in group 1 than group 2, a more than doubling in the odds of evidence-concordant ordering (OR, 2.56, 95% CI, 0.80-8.21). Postintervention, all gains had been reversed with less frequent ordering in group 1 than group 2 (-9.5%, 95% CI, -21.6% to 2.7%). There was no measurable change in opioid prescribing behaviors at any time point. In this randomized clinical trial, use of smartphone app learning modules resulted in statistically significant short-term improvement in some prescribing behaviors. However, this effect was not sustained over the long-term. Additional research is needed to understand how to sustain improvements in care delivery as a result of continuous professional development at the institutional level. ClinicalTrials.gov Identifier: NCT03771482.

Admission and Mortality Patterns in Intensive Care Delivery at Enugu State University of Science and Technology Teaching Hospital: A Three-Year Retrospective Study.

BackgroundThe intensive care unit (ICU) provides critical care to high-risk patients to prevent morbidity and mortality. This requires closer monitoring and better management than the care provided to patients in normal admission wards and non-critical care units. Mortality rates in ICUs in developing countries are remarkably high compared to rates in more developed countries. Evaluating outcomes of treatment is a way to improve the quality of care. Therefore, this study was conducted to review the pattern of admission and outcome in the ICU of Enugu State University of Science and Technology Teaching Hospital (ESUT-TH).MethodologyThis study was a three-year retrospective, descriptive review of all patients admitted to the ICU of ESUT-TH between January 1, 2019, and December 21, 2021. Data were collected from admissions and discharge registers of the ICU ward. Data were analyzed and expressed as frequencies and percentages. Categorical parameters were compared using the chi-squared test, and the significance level was set at p < 0.05.ResultsA total of 179 patients were admitted in the three-year period. Of them, 49.2% were postoperative patients while 21.2% were admitted from the accident and emergency unit. There were a total of 74 (41.3%) medical cases and 81 (45.3%) surgical cases, and the rest were unspecified. Among surgical cases, 19% were from the general surgery department followed by obstetrics and gynecology (18.4%) and neurosurgery (16.8%). Cerebrovascular accidents and traumatic brain injury were the most common specific diagnoses recorded among ICU admitted patients. The most common reason for admission was close monitoring of high-risk patients. The mortality rate during the studied period was 34.1%, and this was significantly associated with patient age and type of illness at presentation (p < 0.05). Stratified by year of admission, the highest rate of mortality was noted in the year 2020 (46.7%).ConclusionThere is a high level of mortality among ICU admissions in our center. This calls for the improvement of intensive care delivery in the healthcare facility, including training and retraining of manpower and provision of essential facilities for high-quality healthcare delivery.

Factors affecting pathways to care for children and adolescents with complex vascular malformations: parental perspectives

BackgroundComplex vascular malformations (VMs) are rare disorders that can cause pain, coagulopathy, disfigurement, asymmetric growth, and disability. Patients with complex VMs experience misdiagnosis, delayed diagnosis, delayed or inappropriate treatments, and worsened health. Given the potential consequences of delaying expert care, we must identify the factors that impede or facilitate this access to care.ResultsWe performed semi-structured interviews with 24 parents (21 mothers; 3 fathers; median age = 42.5 years) of children with complex VMs and overgrowth disorders living in the US, recruited through two patient advocacy groups – CLOVES Syndrome Community, and Klippel-Trenaunay Support Group. We performed thematic analysis to assess parental perspectives on barriers and facilitators to accessing expert care. We identified 11 factors, representing 6 overarching themes, affecting families’ ability to access and maintain effective care for their child: individual characteristics (clinician behaviors and characteristics, parent behaviors and characteristics), health care system (availability of specialist multidisciplinary teams, care coordination and logistics, insurance and financial issues, treatments and services), clinical characteristics (accuracy and timing of diagnosis, features of clinical presentation), social support networks, scientific progress, and luck and privilege. Additionally, access to information about VMs and VM care was a crosscutting theme affecting each of these factors. These factors influenced both the initial access to care and the ongoing maintenance of care for children with VMs.ConclusionParents of children with VMs report multiple factors that facilitate or impede their ability to provide their child with optimal care. These factors represent possible targets for future interventions to improve care delivery for families affected by VMs.

Overuse of Axillary Surgery in Patients with Ductal Carcinoma In Situ: Opportunity for De-escalation.

Ductal carcinoma in situ (DCIS) is noninvasive breast cancer and therefore nodal staging is not routinely recommended. We evaluated the use of and factors associated with axillary surgery in DCIS in the National Cancer Database (NCDB). DCIS cases were identified from the NCDB 2012-2018. Use of axillary surgery was evaluated over time, and factors associated with axillary surgery were assessed for breast-conserving surgery (BCS) and mastectomy groups. We identified 178,762 patients, median age of 60 years. Majority of DCIS (87%) was ER-positive, and 14% low, 43% intermediate, and 44% high grade. Median DCIS size was 1.1 cm. BCS was performed in 72%, whereas 28% had mastectomy. Overall axillary surgery was performed in 38% and was higher in patients undergoing mastectomy compared with patients undergoing BCS (88% vs. 19%, p < 0.001). At axillary surgery, the vast majority (92%) had 1-5 nodes examined, whereas 8% had >5 nodes examined. Over time, axillary surgery decreased in BCS patients (21%in 2012 to17%in 2018, p < 0.001) but increased slightly in mastectomy patients (86% in 2012 to90%in 2018, p < 0.001). On multivariable analysis, factors significantly associated with axillary surgery were younger patient age, larger tumor size, higher grade, and ER-negative status. Factors associated with axillary surgery reflect higher risk disease for upstage to invasive cancer, indicating surgeon judgment. However, despite axillary surgery being overtreatment of DCIS, it is common in mastectomy and is performed for one in five patients undergoing BCS. This provides opportunity for improvement in breast cancer care delivery.

Factors Associated with Vesicovaginal Fistula and Their and Treatment Outcome

Vesicovaginal fistulas (VVF) also known as vesicovaginal fistula, have become a growing public health concern especially of developing countries. The most cited reason in literature of VVF is by prolonged and obstructed labor. With improvement in quality care delivery in health around the globe, the etiology of VVF too evolving in the country. Objective: This study was done to find out the factors associated with vesicovaginal fistula and to determine the success rate of operative procedure for treatment of vesicovaginal fistula. Method: This cross sectional study was carried out in Department of Gyneacology and Obstetrics in Liaquat University Hospital, Hyderabad from January 2021 to December 2021 among 60 women at different ages suffering from vesicovaginal fistula due to gynaecological or obstetrical causes or malignancy. Result: Majority of the patients were “young primipara with short stature and malnourished, coming from lower socioeconomic condition of rural areas. Prolonged labor 24 (40%) was the most common cause of vesicovaginal fistula, followed by gynaecological surgeries mainly hysterectomies 18 (30%) and malignancy 4 (6.6%) rare cause. The success rate of repair following first and second attempt was 92% and 8% respectively. Overall success rate was 48 (96%) and functionally failed with a failure in 2(4%) cases. This study showed main cause for developing fistula showing prolonged labor and majority of patient were treated pervaginally. Most of the cases (96%) had successful repair which is very encouraging and correlates well with recently published series. Conclusion: Fistula can be totally preventable by proper antenatal care identification of high risk cases, timely referral, proper intranatal, postnatal care, and proper training. So improvement of health care services and dedication will prevent this type of morbidity. The best results are obtained when repair of vesicovaginal fistulae is carried out under optimal conditions”.

How Adolescents and Young Adults with Cancer Experience an Age-Appropriate Intervention When Undergoing Treatment in Adult Surgery Clinics: A Qualitative Study.

Purpose: Despite growing international attention, few interventions specifically target adolescents and young adults (AYAs) with cancer even though appropriate interventions may improve care delivery during cancer treatment. The study's purpose was to explore how AYAs with cancer experience an age-appropriate intervention when undergoing treatment in adult surgery clinics. Methods: Twenty AYAs with cancer, aged 18-29 years, from five surgery clinics at Copenhagen University Hospital Rigshospitalet participated in an intervention consisting of three main components: care provided by trained youth coordinator nurses (YCNs) to the greatest extent possible; a 1-hour one-on-one conversation with a YCN during hospitalization; and a postdischarge phone call. Semistructured interviews were used to collect data, which were analyzed in a stepwise process based on inductive content analysis. Results: Three themes were identified: a beacon in the dark; from patient to person; and the caring check-up. Participants felt safe and experienced a sense of presence and a caring environment in a significant and trusting relationship with YCNs, which encouraged them to share thoughts, feelings, and needs they previously had kept silent about. The one-on-one conversations helped them begin reflecting and in emotional processing and the postdischarge phone call was perceived as a caring check-up. Conclusions: The study shows how an age-appropriate intervention was experienced overall as meaningful for the participants hospitalized in adult surgery clinics, but more research is required to further examine the significance and effect of interventions that target AYAs with cancer.

Exploring Health Care Providers' Experiences of Providing Collaborative Palliative Care for Patients With Advanced Heart Failure At Home: A Qualitative Study.

BackgroundThe HeartFull Collaborative is a regionally organized model of care which involves specialist palliative care and cardiology health care providers (HCPs) in a collaborative, home‐based palliative care approach for patients with advanced heart failure (AHF). We evaluated HCP perspectives of barriers and facilitators to providing coordinated palliative care for patients with AHF at home.Methods and ResultsWe conducted a qualitative study with 17 HCPs (11 palliative care and 6 cardiology) who were involved in the HeartFull Collaborative from April 2013 to March 2020. Individual, semi‐structured interviews were held with each practitioner from November 2019 to March 2020. We used an interpretivist and inductive thematic analysis approach. We identified facilitators at 2 levels: (1) individual HCP level (on‐going professional education to expand competency) and (2) interpersonal level (shared care between specialties, effective communication within the care team). Ongoing barriers were identified at 2 levels: (1) individual HCP level (e.g. apprehension of cardiology practitioners to introduce palliative care) and (2) system level (e.g. lack of availability of personal support worker hours).ConclusionsOur results suggest that a collaborative shared model of care delivery between palliative care and cardiology improves knowledge exchange, collaboration and communication between specialties, and leads to more comprehensive patient care. Addressing ongoing barriers will help improve care delivery. Findings emphasize the acceptability of the program from a provider perspective, which is encouraging for future implementation. Further research is needed to improve prognostication, assess patient and caregiver perspectives regarding this model of care, and assess the economic feasibility and impact of this model of care.

Équipe mobile de pédopsychiatrie en territoire guyanais : questionnement de l’adolescent amérindien

IntroductionSince their French naturalization in 1969, Amerindians of French Guiana have been facing a full and fast reorganization of their way of life. Teenagers, at the forefront of this cultural transition, are challenging French school institutions, as well as cultural society and care system organizations in Amazonian French remote villages. Rates of autolytic behaviors such as toxic substance abuse or suicide attempts, but mostly completed suicides, are alarming among this adolescent population. To improve care delivery to those teenagers, a mobile child psychiatric team was implemented in 2013. MethodsWe describe this device, its activities and the problematics encountered. ResultsThis team's purpose is to lead a psychiatric evaluation of teenagers in order to determine a possible psychiatric diagnosis and elaborate a care plan. Although the results are mostly encouraging, this device seems to show some limitations: lack of time dedicated to these interventions, lack of psychiatric care available for follow-up in these villages, tremendous numbers of social distress situations implicated in psychological issues. Moreover, it appears that cultural aspects must be considered in the analysis of the Amerindian adolescent population's issues and the determination of providing care. ConclusionImplementation of actions based on more educational and social levels might be a solution.

Advancing Nursing Science Through Site-Based Clinical Inquiry: Designing Problem Pyramids.

Advancing Nursing Science Through Site-Based Clinical Inquiry: Designing Problem Pyramids.

A Collaborative Psychiatric-Genetics Inpatient Care Delivery Model Improves Access to Clinical Genetic Evaluation, Testing, and Diagnosis for Patients With Neurodevelopmental Disorders.

Neurodevelopmental disorders including autism spectrum disorder, intellectual disability, and global developmental delay are among the most common indications for referral to clinical genetics evaluation; and clinical genetic testing is indicated for people with neurodevelopmental disorders. There are known barriers to care in accessing clinical genetics evaluation for this patient population. We created a collaborative psychiatric–genetics consultation service and psychiatric–genetics outpatient clinic with the goal to improve care delivery to patients with neurodevelopmental disorders. Two years after the launch of this pilot program, our data demonstrate improved access to genetics evaluation with shorter wait times and fewer patients lost to follow-up. Perhaps most importantly, new genetic diagnoses changed medical care for the majority of patients.

Severe Fetal CAKUT (Congenital Anomalies of the Kidneys and Urinary Tract), Prenatal Consultations, and Initiation of Neonatal Dialysis.

Pediatric nephrology prenatal consultations for congenital anomalies of the kidney and urinary tract (CAKUT) and criteria for kidney replacement therapy initiation in neonatal end-stage kidney disease (ESKD) are not well described. We evaluated pediatric nephrology approaches to prenatal CAKUT counseling and neonatal dialysis initiation. A 35-question Qualtrics survey was distributed via the North American Pediatric Renal Trials and Collaborative Studies email list between January and March 2021. Thirty-nine pediatric nephrology centers completed the survey. All but one responding center (n = 38) provide prenatal CAKUT consultations and neonatal dialysis, with wide variability in reported multispecialty involvement. Nearly half (47%) of centers utilize written/unwritten criteria for offering neonatal dialysis. The most common contraindications to neonatal dialysis were parental refusal (61%), contraindication to access placement by surgeons (55%), and birth weight (BW) contraindication (55%, with < 1,500 g being the most common BW contraindication). Overall, 79% of centers reported caring for < 5 neonates with ESKD in the past year, 61% use hemodialysis therapies prior to peritoneal dialysis in neonates requiring dialysis, and 100% transition to peritoneal dialysis by hospital discharge. Many pediatric nephrology programs provide prenatal CAKUT consultations and neonatal dialysis, but with variability in practice approach. Further multicenter research regarding prenatal consultations and neonatal dialysis outcomes is necessary to further improve care delivery to this population.

Partnership working between nurses and patients' families in the critical care environment.

When an individual becomes critically ill, they may be admitted to a critical care environment, which can have significant effects on themselves and their family. There is a wealth of literature exploring the experiences and priorities of patients and their families in relation to critical care, but also a lack of research on practical interventions that can improve care delivery in this setting. This article explores partnership working between nurses and patients' families in the critical care environment and examines the barriers to, and facilitators of, family-centred care. The author draws on the literature to consider interventions that could enhance family-centred care in this setting, and makes some recommendations for practice.

Presentation, Diagnosis and Treatment Delays in Breast Cancer Care and Their Associations in Sri Lanka, a Low-resourced Country

AimsDelays in breast cancer care, one important attributable factor for breast cancer being diagnosed at advanced stages, are not systematically studied in many countries. This study assessed the magnitude and factors associated with delays in breast cancer care in Sri Lanka, from symptom detection to treatment initiation. Materials and methodsWe interviewed 800 consecutively sampled female breast cancer patients, diagnosed within the last 12 months, using context-specific questionnaires and medical records. We defined the cut-off times for delays using international guidelines and features of the national health system and care-seeking patterns in the country. Delays were estimated as proportions with 95% confidence intervals and presented for: (i) presentation delay; (ii) diagnosis delay and (iii) treatment delay. We looked at how sociodemographic and healthcare availability and accessibility at the individual level were associated with delays using multivariate logistic regression, with a P value of 0.05 to define statistical significance. ResultsNearly two-thirds of patients reported a presentation delay (63.3%, 95% confidence interval 59.9–66.6%). A diagnosis delay (36.7%, 95% confidence interval 33.4–40.0%) was also seen among one-third, whereas treatment delays (13.2%, 95% confidence interval 10.8–15.5%) were less common. Low family monthly income (odds ratio 6.3; 95% confidence interval 4.2–9.3) and poor knowledge on breast cancer (odds ratio 2.7; 95% confidence interval 1.8–3.8) were associated with presentation delay. Poor health literacy (odds ratio 1.7; 95% confidence interval 1.1–2.7) and the need to make more than two visits to the first contact health provider prior to diagnosis (odds ratio 7.2; 95% confidence interval 4.6–11.1) were associated with diagnosis delays, whereas directly contacting an appropriate specialised health provider once the lump was detected reduced diagnosis delay (odds ratio 0.3; 95% confidence interval 0.2–0.4). Having undergone a core biopsy (odds ratio 0.5; 95% confidence interval 0.3–0.8) and having a mammogram (odds ratio 0.6; 95% confidence interval 4.7–32.7) reduced the likelihood of treatment delays. ConclusionsOur study findings show that delays in breast cancer care in Sri Lanka are much lower than those in other lower-middle income countries. However, there is significant room for improvement, especially in relation to the excellence in quality of care, such as improving access to mammography services. Periodical estimation of breast cancer delays enabling temporal comparisons will probably provide useful information to policy makers in improving care delivery for breast cancer patients and, hence, is recommended. Such future assessments designed for comparisons between different treatment modalities would provide more information to assist policy decisions in care improvement.