The Dartmouth Institute for Health Policy and Clinical Practice at Geisel School of Medicine, Dartmouth College, WTRB Level 5, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
New York University School of Global Public Health, 708 Broadway, New York, NY, 10003, USA.
BMC Palliat Care. 2023 May 16;22(1):59. doi: 10.1186/s12904-023-01182-9.
Early access to specialty palliative care is associated with better quality of life, less intensive end-of-life treatment and improved outcomes for patients with advanced cancer. However, significant variation exists in implementation and integration of palliative care. This study compares the organizational, sociocultural, and clinical factors that support or hinder palliative care integration across three U.S. cancer centers using an in-depth mixed methods case study design and proposes a middle range theory to further characterize specialty palliative care integration.
Mixed methods data collection included document review, semi-structured interviews, direct clinical observation, and context data related to site characteristics and patient demographics. A mixed inductive and deductive approach and triangulation was used to analyze and compare sites' palliative care delivery models, organizational structures, social norms, and clinician beliefs and practices.
Sites included an urban center in the Midwest and two in the Southeast. Data included 62 clinician and 27 leader interviews, observations of 410 inpatient and outpatient encounters and seven non-encounter-based meetings, and multiple documents. Two sites had high levels of "favorable" organizational influences for specialty palliative care integration, including screening, policies, and other structures facilitating integration of specialty palliative care into advanced cancer care. The third site lacked formal organizational policies and structures for specialty palliative care, had a small specialty palliative care team, espoused an organizational identity linked to treatment innovation, and demonstrated strong social norms for oncologist primacy in decision making. This combination led to low levels of specialty palliative care integration and greater reliance on individual clinicians to initiate palliative care.
Integration of specialty palliative care services in advanced cancer care was associated with a complex interaction of organization-level factors, social norms, and individual clinician orientation. The resulting middle range theory suggests that formal structures and policies for specialty palliative care combined with supportive social norms are associated with greater palliative care integration in advanced cancer care, and less influence of individual clinician preferences or tendencies to continue treatment. These results suggest multi-faceted efforts at different levels, including social norms, may be needed to improve specialty palliative care integration for advanced cancer patients.
早期获得专科姑息治疗与提高生活质量、减少生命终末期强化治疗以及改善晚期癌症患者结局有关。然而，姑息治疗的实施和整合存在显著差异。本研究采用深入的混合方法病例研究设计，比较了三个美国癌症中心在组织、社会文化和临床方面支持或阻碍姑息治疗整合的因素，并提出了一个中程理论，以进一步描述专科姑息治疗的整合。
混合方法数据收集包括文件审查、半结构化访谈、直接临床观察以及与站点特征和患者人口统计学相关的背景数据。采用混合归纳和演绎方法以及三角测量法分析和比较了各站点的姑息治疗提供模式、组织结构、社会规范以及临床医生的信念和实践。
三个站点包括中西部的一个城市中心和东南部的两个站点。数据包括 62 名临床医生和 27 名领导的访谈、410 次住院和门诊会诊的观察以及 7 次非会诊会议和多项文件。两个站点具有高度有利于专科姑息治疗整合的“有利”组织影响因素，包括筛查、政策和其他促进将专科姑息治疗整合到晚期癌症治疗中的结构。第三个站点缺乏专科姑息治疗的正式组织政策和结构，专科姑息治疗团队规模较小，崇尚与治疗创新相关的组织身份，并表现出以肿瘤医生为主导决策的强烈社会规范。这种组合导致专科姑息治疗的整合程度较低，更多地依赖于个别临床医生来启动姑息治疗。
在晚期癌症治疗中整合专科姑息治疗服务与组织层面因素、社会规范和个别临床医生的定位的复杂相互作用有关。由此产生的中程理论表明，专科姑息治疗的正式结构和政策与支持性社会规范相结合，与晚期癌症治疗中更高的姑息治疗整合度相关，而与个别临床医生的偏好或继续治疗的倾向的影响较小。这些结果表明，可能需要在不同层面上采取多方面的努力，包括社会规范，以改善晚期癌症患者的专科姑息治疗整合。
