Introduction: Understanding and Influencing Multilevel Factors Across the Cancer Care Continuum

Abstract

Health care in the United States is notoriously expensive while often failing to deliver the care recommended in published guidelines. There is, therefore, a need to consider our approach to health-care delivery. Cancer care is a good example for consideration because it spans the continuum of health-care issues from primary prevention through long-term survival and end-of-life care. In this monograph, we emphasize that health-care delivery occurs in a multilevel system that includes organizations, teams, and individuals. To achieve health-care delivery consistent with the Institute of Medicine's six quality aims (safety, effectiveness, timeliness, efficiency, patient-centeredness, and equity), we must influence multiple levels of that multilevel system. The notion that multiple levels of contextual influence affect behaviors through interdependent interactions is a wellestablished ecological view. This view has been used to analyze health-care delivery and health disparities. However, experience considering multilevel interventions in health care is much less robust. This monograph includes 13 chapters relevant to expanding the foundation of research for multilevel interventions in health-care delivery. Subjects include clinical cases of multilevel thinking in health-care delivery, the state of knowledge regarding multilevel interventions, study design and measurement considerations, methods for combining interventions, time as a consideration in the evaluation of effects, measurement of effects, simulations, application of multilevel thinking to health-care systems and disparities, and implementation of the Affordable Care Act of 2010. Our goal is to outline an agenda to proceed with multilevel intervention research, not because it guarantees improvement in our current approach to health care, but because ignoring the complexity of the multilevel environment in which care occurs has not achieved the desired improvements in care quality outlined by the Institute of Medicine at the turn of the millennium.

Primary care providers’ cancer genetic testing-related knowledge, attitudes, and communication behaviors: A systematic review and research agenda

“…Furthermore, this review focused predominantly on broad research trends and gaps from the perspective of PCPs, thereby not addressing patient perspectives, social factors (e.g., racism), or healthcare system factors (e.g., clinical decision support) that can influence care delivery. 81 This review did not focus on how provider characteristics (e.g., training, age) may contribute to differences in the outcomes of interest; future research could explore such differences. Finally, this review does not offer insight into PCPs' experiences with novel applications of genomic testing currently being introduced into cancer care (e.g., multi-gene panel testing, although a reviewed article noted that 42% of providers have ordered such testing 39 ).…”

The Meaning of Survivorship as Defined by African American Breast Cancer Survivors

“…A number of studies revealed a fragmented delivery care system (Bourjolly, Hirschman, & Zieber, 2004) and barriers to communication (Tapin et al, 2012). Given that many AABCS embodied and embraced the definition and meaning of survivorship and the resulting themes (altruism, spirituality, resilience, and thriving), they appear to be well equipped and should be sought for the role of Survivor's Navigators.…”

Inadequate Systems to Support Breast and Cervical Cancer Screening in Primary Care Practice

“…Conceptual models of cancer screening identify a role for risk assessment and communication between providers and patients as important aspects of effective screening processes. [4][5][6][7] Prior studies indicate that the adoption of system-based strategies such as health information technology (HIT) and decision support improves the quality of primary care delivery, including uptake of cancer screening. [8][9][10] However, they also report a lack of HIT and practice-based systems to support screening in primary care.…”