Ridgeway Jennifer L, Boardman Lisa A, Griffin Joan M, Beebe Timothy J
Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, 55905, USA.
Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA.
Implement Sci Commun. 2021 Aug 25;2(1):92. doi: 10.1186/s43058-021-00190-1.
Despite overall declines in cancer mortality in the USA over the past three decades, many patients in community settings fail to receive evidence-based cancer care. Networks that link academic medical centers (AMCs) and community providers may reduce disparities by creating access to specialized expertise and care, but research on network effectiveness is mixed. The objective of this study was to identify factors related to whether and how an exemplar AMC network served to provide advice and referral access in community settings.
An embedded in-depth single case study design was employed to study a network in the Midwest USA that connects a leading cancer specialty AMC with community practices. The embedded case units were a subset of 20 patients with young-onset colorectal cancer or risk-related conditions and the providers involved in their care. The electronic health record (EHR) was reviewed from January 1, 1990, to February 28, 2018. Social network analysis identified care, advice, and referral relationships. Within-case process tracing provided detailed accounts of whether and how the network provided access to expert, evidence-based care or advice in order to identify factors related to network effectiveness.
The network created access to evidence-based advice or care in some but not all case units, and there was variability in whether and how community providers engaged the network, including the path for referrals to the AMC and the way in which advice about an evidence-based approach to care was communicated from AMC specialists to community providers. Factors related to instances when the network functioned as intended included opportunities for both rich and lean communication between community providers and specialists, coordinated referrals, and efficient and adequately utilized documentation systems.
Network existence alone is insufficient to open up access to evidence-based expertise or care for patients in community settings. In-depth understanding of how this network operated provides insight into factors that support or inhibit the potential of networks to minimize disparities in access to evidence-based community cancer care, including both personal and organizational factors.
尽管在过去三十年中美国癌症死亡率总体呈下降趋势，但许多社区患者仍无法获得基于证据的癌症护理。连接学术医疗中心（AMC）和社区医疗服务提供者的网络可能通过提供专业知识和护理途径来减少差异，但关于网络有效性的研究结果不一。本研究的目的是确定与一个典型的AMC网络是否以及如何在社区环境中提供建议和转诊服务相关的因素。
采用嵌入式深度单案例研究设计，对美国中西部一个将领先的癌症专科AMC与社区医疗机构相连的网络进行研究。嵌入式案例单元是20例青年期结直肠癌或相关风险疾病患者及其护理过程中涉及的医疗服务提供者。回顾了1990年1月1日至2018年2月28日的电子健康记录（EHR）。社会网络分析确定了护理、建议和转诊关系。案例内过程追踪详细说明了该网络是否以及如何提供获得专家、基于证据的护理或建议的途径，以确定与网络有效性相关的因素。
该网络在部分而非所有案例单元中提供了基于证据的建议或护理途径，社区医疗服务提供者参与该网络的方式和程度存在差异，包括转诊至AMC的途径以及AMC专家向社区医疗服务提供者传达基于证据的护理方法建议的方式。与网络按预期发挥作用的情况相关的因素包括社区医疗服务提供者与专家之间丰富和简洁沟通的机会、协调的转诊以及高效且充分利用的文档系统。
仅靠网络的存在不足以让社区患者获得基于证据的专业知识或护理。深入了解该网络的运作方式有助于洞察支持或抑制网络减少基于证据的社区癌症护理获取差异潜力的因素，包括个人和组织因素。
