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The interventions used in cancer-survivorship care do not always address outcomes important to survivors. This study sought to understand stakeholders’ views on the key concerns of cancer survivors after treatment and the interventions needed to meet survivors’ and families’ psychosocial needs after completing cancer treatment. We conducted a descriptive qualitative study using semi-structured interviews with stakeholders (survivors, family/friend caregivers, oncology providers, primary care providers, and cancer system decision-/policy-makers) from across Canada. For the data analysis, we used techniques commonly employed in descriptive qualitative research, such as coding, grouping, detailing, and comparing the data. There were 44 study participants: 11 survivors, seven family/friend caregivers, 18 health care providers, and eight decision-/policy-makers. Stakeholder-relevant interventions to address survivors’ psychosocial needs were categorized into five groups, as follows: information provision, peer support, navigation, knowledge translation interventions, and caregiver-specific supports. These findings, particularly interventions that deliver timely and relevant information about the post-treatment period and knowledge translation interventions that strive to integrate effective tools and programs into survivorship care, have implications for future research and practice.

ObjectivesWe will enrich the cancer research ecosystem in Canada through linking cancer registry and administrative health data to the Canadian Partnership for Tomorrow’s Health (CanPath) cohort and biobank. CanPath is Canada’s largest population health study, including 1% of the Canadian population, which seeks to investigate cancer development. ApproachWe are achieving record-level linkage of the CanPath harmonized dataset to provincial cancer registry data, and hospitalization and ambulatory care data from the Canadian Institutes of Health Information (CIHI). The CanPATH harmonized dataset includes comprehensive genetics, environment, lifestyle, and behaviour data. Our linkage activities will result in interprovincial data sharing, with centrally-held linked data, a first in Canadian history. We will demonstrate the CanPath-cancer registry-CIHI linkage potential by investigating the impact of the COVID-19 pandemic on healthcare utilization and outcomes among those with cancer. ResultsThe linkage is ongoing and anticipated to be completed by September 2022. Linked data will be made available through the CanPath Data Safe Haven, a cloud-based solution that meets the legal requirements of the data sharing agreements and provincial privacy policies, and is accessible to researchers through secure access. The CanPath Data Safe Haven will be a federated data platform for Canadian researchers to access, analyze, and contribute research in a collaborative environment. By linking these datasets, this project will: address concerns related to accessibility of cancer data in Canada; bring more value to existing data; support an enhanced understanding of the impacts of cancer on marginalized populations; and create a more integrated approach to cancer data access and management. ConclusionCanPath will be the first program in Canadian history to combine the wealth of cohort resources with cancer registry and administrative health data in a central location at a national scale. We will provide a single point of access for researchers to conduct novel investigations into cancer development and outcomes.

ObjectivesTo link population-based survey data to routinely collected administrative health data to enable investigation of how cancer survivors' ongoing physical, emotional, and practical needs and experiences after completing cancer treatment impact their healthcare utilization, including discharge from oncology to primary care. ApproachThe "Cancer Transitions Survey" is a population-based survey examining survivors' experiences and needs after completing cancer treatment. The survey was administered by the Nova Scotia Cancer Registry (NSCR) as part of a national study, the largest of its kind in Canada. Respondents included Nova Scotian survivors of breast, melanoma, colorectal, prostate, hematologic, and young adult cancers who were 1-3 years after treatment. Survey responses were linked to cancer registry, physicians' claims, hospitalization, and ambulatory care data. The data linkage provided a full four years of healthcare utilization data for each cancer survivor, beginning one year after their cancer diagnosis. Results1557 survivors responded to the survey and subsequently had their data linked. Collectively, breast, colorectal, and prostate cancer survivors represented 78.5% of survey respondents. Most respondents (65.3%) were 65 years of age or older and 69.8% had an existing co-morbid condition. Regression analyses are now being conducted to investigate whether the type and magnitude of post-treatment care needs, and the interventions (services and supports) received, impact health care utilization in the survivorship period, including discharge to primary care. ConclusionThis study represents a unique opportunity to link data unavailable in administrative health data: namely, self-reported needs and use of non-physician services and supports (e.g., support groups, counselling). As such, this dataset permits investigation of healthcare utilization and patterns of care that cannot be accomplished using administrative health data alone.

After treatment, cancer survivors require ongoing, comprehensive care to improve quality of life, reduce disability, limit complications, and restore function. In Canada and internationally, follow-up care continues to be delivered most often by oncologists in institution-based settings. There is extensive evidence to demonstrate that this model of care does not work well for many survivors or our cancer systems. Randomized controlled trials have clearly demonstrated that alternate approaches to follow-up care are equivalent to oncologist-led follow-up in terms of patient outcomes, such as recurrence, survival, and quality of life in a number of common cancers. In this paper, we discuss the state of follow-up care for survivors of prevalent cancers and the need for more personalized models of follow-up. Indeed, there is no one-size-fits-all solution to post-treatment follow-up care, and more personalized approaches to follow-up that are based on individual risks and needs after cancer treatment are warranted. Canada lags behind when it comes to personalizing follow-up care for cancer survivors. There are many reasons for this, including difficulty in determining who is best served by different follow-up pathways, a paucity of evidence-informed self-management education and supports for most survivors, poorly developed IT solutions and systems, and uneven coordination of care. Using implementation science theories, approaches, and methods may help in addressing these challenges and delineating what might work best in particular settings and circumstances.

Background: This study aimed to understand Canadian cancer survivors’ experiences during the return-to-work (RTW) process. Methods: A prospective qualitative longitudinal design was employed using the principles of phenomenological inquiry. Cancer survivors took part in three in-depth interviews: at the end of treatment, and 3 and 9 months after the first interview. Transcripts were analyzed using constant comparative analysis, guided by the Cancer and Work model. Results: A total of 38 in-depth interviews were conducted with 13 participants. The resultant themes were: (1) supports received or desired to enable RTW; (2) others’ limited understanding of the long-term impacts of a cancer diagnosis and its treatment; (3) worries and self-doubts about returning to work; and (4) changing perspectives on life and work after cancer. Conclusions: Cancer patients returning to work after treatment often experience challenges throughout the process, including varying levels of support from others and a range of ongoing effects and motivation to RTW. There is a clear gap in terms of the professional supports available to these individuals. Future research should focus on investigating how to improve both quality and accessibility of supports in a way that is personalized to the individual.

ObjectiveTo explore the views of underserved and equity-denied communities in Nova Scotia, Canada, regarding organ and tissue donation and deemed consent legislation.DesignA qualitative descriptive study was undertaken, employing both interviews and focus groups.SettingThe province of Nova Scotia, Canada—the first jurisdiction in North America to implement deemed consent legislation for organ and tissue donation.ParticipantsLeaders of African Nova Scotian, Lesbian, Gay, Bisexual, Trans, Queer, Two Spirit (LGBTQ2S+) and Faith-based communities (Islam and Judaism) were invited to participate (n=11). Leaders were defined as persons responsible for community organisations or in other leadership roles, and were purposively recruited by the research team.ResultsThrough thematic analysis, four main themes were identified: (1) alignment with personal values as well as religious beliefs and perspectives; (2) trust and relationships, which need to be acknowledged and addressed in the context of deemed consent legislation; (3) cultural competence, which is essential to the roll-out of the new legislation and (4) communication and information to combat misconceptions and misinformation, facilitate informed decision-making, and mitigate conflict within families.ConclusionsLeaders of African Nova Scotian, LGBTQ2S+ and Faith-based communities in Nova Scotia are highly supportive of deemed consent legislation. Despite this, many issues exemplify the need for cultural competence at all levels. These findings should inform ongoing implementation of the legislation and other jurisdictions considering a deemed consent approach to organ and tissue donation.

The cancer diagnostic process can be protracted, and it is a time of great anxiety for patients. The objective of this study was to examine inter- and intra-provincial variation in diagnostic intervals and explore factors related to the variation. This was a multi-province retrospective cohort study using linked administrative health databases. All females with a diagnosis of histologically confirmed invasive breast cancer in British Columbia (2007–2010), Manitoba (2007–2011), Ontario (2007–2010), Nova Scotia (2007–2012), and Alberta (2004–2010) were included. The start of the diagnostic interval was determined using algorithms specific to whether the patient’s cancer was detected through screening. We used multivariable quantile regression analyses to assess the association between demographic, clinical and healthcare utilization factors with the diagnostic interval outcome. We found significant inter- and intra-provincial variation in the breast cancer diagnostic interval and by screen-detection status; patients who presented symptomatically had longer intervals than screen-detected patients. Interprovincial diagnostic interval variation was 17 and 16 days for screen- and symptom-detected patients, respectively, at the median, and 14 and 41 days, respectively, at the 90th percentile. There was an association of longer diagnostic intervals with increasing comorbid disease in all provinces in non-screen-detected patients but not screen-detected. Longer intervals were observed across most provinces in screen-detected patients living in rural areas. Having a regular primary care provider was not associated with a shorter diagnostic interval. Our results highlight important findings regarding the length of the breast cancer diagnostic interval, its variation within and across provinces, and its association with comorbid disease and rurality. We conclude that diagnostic processes can be context specific, and more attention should be paid to developing tailored processes so that equitable access to a timely diagnosis can be achieved.

IntroductionIn Canada, most provinces have established administrative health data repositories to facilitate access to these data for research. Anecdotally, researchers have described delays and substantial inter-provincial variations in the timeliness of data access approvals and receipt of data. Currently, the reasons for these delays and variations in timeliness are not well understood. This paper provides a study protocol for (1) identifying the factors affecting access to administrative health data for research within select Canadian provinces, and (2) comparing factors across provinces to assess whether and how they contribute to inter-provincial variations in access to administrative health data for research. MethodsA qualitative, multiple-case study research design will be used. Three cases will be included, representing three different provinces. For each case, data will be collected from documents and interviews. Specifically, interviews will be carried out with (1) research stakeholders, and (2) regulatory stakeholders (10 individuals/group*,2 groups/province * 3 provinces =$ 60). During within-case analysis, interview data for each stakeholder group will be analyzed separately using constant comparative analysis. Document analysis will occur iteratively, and will inform interview guide adaptation, and supplement interview data. Cross-case analysis will involve systematic comparison of findings across cases. DiscussionThis study represents the first in-depth examination of access to administrative health data in Canada. The main outcome will be an overarching mid-range theory explaining inter-provincial variations in access to administrative health data in Canada. This theory will be strengthened by the inclusion of the perspectives of both researchers and those involved in the regulation of data access. The findings from this study may be used to improve equitable and timely access to administrative health data across provinces, and may be transferable to other jurisdictions where barriers to access to administrative health data have been reported.

OBJECTIVE: Breast cancer screening aims to identify cancers in early stages when prognosis is better and treatments less invasive. We describe inter- and intra-provincial variation in the percentage of screen-detected cases under publicly funded healthcare systems and factors related to having screen- vs non-screen-detected breast cancer across five Canadian provinces. METHODS: Women aged 40+ diagnosed with incident breast cancer from 2007 to 2012 in five Canadian provinces were identified from their respective provincial cancer registries. Standardized provincial datasets were created linking screening, health administrative, and claims data. Province-specific logistic regression models were used to evaluate the association of demographic and healthcare utilization factors in each province with the odds of screen-detected cancer. RESULTS: There was significant inter- and intra-provincial variation by age. Screen detection ranged from 42% to 52% in ages 50–69 but women aged 50–59 had approximately 4–8% lower screen detection than those aged 60–69 in all provinces. Screening associations with income quintile and rurality varied across provinces. Those least likely to be screen-detected within a province were consistently in the lowest income quintile; OR ranged from 0.62–0.89 relative to highest income quintile/urban patients aged 50–69. Lack of visits to primary care 30 months prior to diagnosis was also consistently associated with lower odds of screen detection (OR range, 0.37–0.76). CONCLUSION: Breast cancer screen detection rates in the Canadian provinces examined are relatively high. Associations with income-rurality indicate a need for greater attention and/or targeted outreach to specific communities and/or provincial regions to improve access to breast cancer screening services intra-provincially.

Chemotherapy has improved outcomes in early-stage breast cancer, but treatment practices vary, and use of acute care is common. We conducted a pan-Canadian study to describe treatment differences and the incidence of emergency department visits (edvs), edvs leading to hospitalization (edvhs), and direct hospitalizations (hs) during adjuvant chemotherapy. The cohort consisted of women diagnosed with early-stage breast cancer (stages i&ndash, iii) during 2007&ndash, 2012 in British Columbia, Manitoba, Ontario, or Nova Scotia who underwent curative surgery. Parallel provincial analyses were undertaken using linked clinical, registry, and administrative databases. The incidences of edvs, edvhs, and hs in the 6 months after treatment initiation were examined for patients treated with adjuvant chemotherapy. The cohort consisted of 50,224 patients. The proportion of patients who received chemotherapy varied by province, with Ontario having the highest proportion (46.4%), and Nova Scotia, the lowest proportion (38.0%). Age, stage, receptor status, comorbidities, and geographic location were associated with receipt of chemotherapy in all provinces. Ontario had the highest proportion of patients experiencing an edv (36.1%), but the lowest proportion experiencing h (6.4%). Conversely, British Columbia had the lowest proportion of patients experiencing an edv (16.0%), but the highest proportion experiencing h (26.7%). The proportion of patients having an edvh was similar across provinces (13.9%&ndash, 16.8%). Geographic location was associated with edvs, edvhs, and hs in all provinces. Intra- and inter-provincial differences in the use of chemotherapy and acute care were observed. Understanding variations in care can help to identify gaps and opportunities for improvement and shared learnings.

Nous avons examine la qualite des soins fournis aux personnes âgees fragiles dans cinq provinces canadiennes a partir de donnees administratives sur la sante. Dans chaque province, nous avons considere les personnes âgees fragiles en fonction de deux cohortes : les personnes decedees et les personnes vivantes. Des regles de decision ont ete utilisees pour determiner quelles personnes etaient freles, soit celles residant en etablissement de soins de longue duree, qui etaient en phase terminale ou dont le profil correspondait a deux des sept domaines identifies. Ces domaines etaient fondes sur des echelles de fragilite, des discussions avec des geriatres et des indicateurs d'utilisation des services de sante. Nous avons evalue la qualite des soins a l'aide des indicateurs de qualite suivants : diminution de la duree de l'hospitalisation, diminution du nombre de readmissions a l'hopital, diminution du nombre de visites a l'urgence, augmentation de la continuite des soins fournis par un medecin de famille, diminution de l'utilisation de la ventilation mecanique et diminution du nombre d'admissions aux soins intensifs. A l'aide d'analyses de regression, nous avons egalement constate que le sexe masculin et l'âge avance etaient associes a une moins bonne qualite de soins dans les deux cohortes. Cette etude fournit des donnees de base qui permettront d'evaluer les futurs efforts visant a ameliorer la qualite des soins offerts aux personnes âgees fragiles. We examined the quality of care provided to older persons with frailty in five Canadian provinces, using administrative health data. In each province, we identified two cohorts of older persons with frailty: decedents and living persons. Using decision rules, we considered individuals to be frail if they were long-term care residents, terminally ill, or met at least two of seven domains, which were based on frailty scales, geriatrician discussions, and health service utilization indicators. We assessed quality of care using selected quality indicators: decrease in length of hospital stay, decrease in the number of in-patient readmissions, decrease in the number of emergency department visits, increase in the level of family physician continuity of care, decrease in the use of mechanical ventilation, and decrease in the number of admissions to intensive care. Using regression analyses, we also found male sex and older age were associated with poorer quality of care in both cohorts. This study provides baseline data for evaluating future efforts to improve the quality of care provided to older persons with frailty.

Background In order to maximize later health, there are established components and guidelines for quality follow-up care of breast cancer survivors. However, adherence to quality follow-up in Canada may not be optimal, and may vary by province. We determined and compared the proportion of patients in each province who received adherent and non-adherent surveillance for recurrence, new cancers and late effects, recommended preventive care, and recommended physician visits for comorbidities. Methods Cohorts consisted of all adult women diagnosed with incident invasive breast cancer between 2007 and 2010/2012 in four Canadian provinces (British Columbia (BC) N = 9338; Manitoba N = 2688; Ontario N = 23,700; Nova Scotia (NS) N = 2735), identified from provincial cancer registries, alive and cancer-free at 30 months post-diagnosis. Their healthcare utilization was determined from one to 5 years post-treatment, using linked administrative databases. Adherence, underuse, and overuse of recommended services were evaluated yearly and compared using descriptive statistics. Results In all provinces and follow-up years, the majority of survivors had more than the recommended number of visits to either an oncologist or primary care physician (range 53.8% NS Year 3; 85.8% Ontario Year 4). The proportion of patients with the guideline-recommended number of oncologist visits varied by province (range 29.8% BC Year 5; 74.8% Ontario Year 5), and the proportion of patients with less than the recommended number of specified breast cancer-related visits with either an oncologist or primary care physician ranged from 32.6% (Ontario Year 2) to 84.4% (NS Year 3). Underuse of surveillance breast imaging was identified in NS and BC. The proportion of patients receiving imaging for metastatic disease (not recommended in the guidelines) in BC, Manitoba, and Ontario (not reported in NS) ranged from 20.3% (BC Year 5) to 53.3% (Ontario Year 2). Compliance with recommended physician visits for patients with several chronic conditions was high in Ontario and NS. Preventive care was less than optimal in all provinces with available data. Conclusions Quality of breast cancer survivor follow-up care varies among provinces. Results point to exploration of factors affecting differences, province-specific opportunities for care improvement, and the value of administrative datasets for health system assessment.

The outcomes assessed in cancer survivorship research do not always match the outcomes that survivors and health system stakeholders identify as most important in the post-treatment follow-up period. This study sought to identify stakeholder-relevant outcomes pertinent to post-treatment follow-up care interventions. We conducted a descriptive qualitative study using semi-structured telephone interviews with stakeholders (survivors, family/friend caregivers, oncology providers, primary care providers, and cancer system decision-/policy-makers) across Canada. Data analysis involved coding, grouping, detailing, and comparing the data by using the techniques commonly employed in descriptive qualitative research. Forty-four participants took part in this study: 11 survivors, seven family/friend caregivers, 18 health care providers, and eight decision-makers. Thirteen stakeholder-relevant outcomes were identified across participants and categorized into five outcome domains: psychosocial, physical, economic, informational, and patterns and quality of care. In the psychosocial domain, one’s reintegration after cancer treatment was described by all stakeholder groups as one of the most important challenges faced by survivors and identified as a priority outcome to address in future research. The outcomes identified in this study provide a succinct suite of stakeholder-relevant outcomes, common across cancer types and populations, that should be used in future research on cancer survivorship care.

Cancer causes substantial emotional and psychosocial distress, which may be exacerbated by delays in treatment. The COVID-19 pandemic has resulted in increased wait times for many patients with cancer. In this study, the psychosocial distress associated with waiting for cancer surgery during the pandemic was investigated. This cross-sectional, convergent mixed-methods study included patients with lower priority disease during the first wave of COVID-19 at an academic, tertiary care hospital in eastern Canada. Participants underwent semi-structured interviews and completed two questionnaires: Hospital Anxiety and Depression Scale (HADS) and Perceived Stress Scale (PSS). Qualitative analysis was completed through a thematic analysis approach, with integration achieved through triangulation. Fourteen participants were recruited, with cancer sites including thyroid, kidney, breast, prostate, and a gynecological disorder. Increased anxiety symptoms were found in 36% of patients and depressive symptoms in 14%. Similarly, 64% of patients experienced moderate or high stress. Six key themes were identified, including uncertainty, life changes, coping strategies, communication, experience, and health services. Participants discussed substantial distress associated with lifestyle changes and uncertain treatment timelines. Participants identified quality communication with their healthcare team and individualized coping strategies as being partially protective against such symptoms. Delays in surgery for patients with cancer during the COVID-19 pandemic resulted in extensive psychosocial distress. Patients may be able to mitigate these symptoms partially through various coping mechanisms and improved communication with their healthcare teams.

Cancer care is complex and exists within the broader healthcare system. The CanIMPACT team sought to enhance primary cancer care capacity and improve integration between primary and cancer specialist care, focusing on breast cancer. In Canada, all medically-necessary healthcare is publicly funded but overseen at the provincial/territorial level. The CanIMPACT Administrative Health Data Group’s (AHDG) role was to describe inter-sectoral care across five Canadian provinces: British Columbia, Alberta, Manitoba, Ontario and Nova Scotia. This paper describes the process used and challenges faced in creating four parallel administrative health datasets. We present the content of those datasets and population characteristics. We provide guidance for future research based on ‘lessons learned’. The AHDG conducted population-based comparisons of care for breast cancer patients diagnosed from 2007-2011. We created parallel provincial datasets using knowledge from data inventories, our previous work, and ongoing bi-weekly conference calls. Common dataset creation plans (DCPs) ensured data comparability and documentation of data differences. In general, the process had to be flexible and iterative as our understanding of the data and needs of the broader team evolved. Inter-sectoral data inconsistencies that we had to address occurred due to differences in: 1) healthcare systems, 2) data sources, 3) data elements and 4) variable definitions. Our parallel provincial datasets describe the breast cancer diagnostic, treatment and survivorship phases and address ten research objectives. Breast cancer patient demographics reflect inter-provincial general population differences. Across provinces, disease characteristics are similar but underlying health status and use of healthcare services differ. Describing healthcare across Canadian jurisdictions assesses whether our provincial healthcare systems are delivering similar high quality, timely, accessible care to all of our citizens. We have provided a description of our experience in trying to achieve this goal and include a list of ‘lessons learned’ and a study process checklist for future use. Key FindingsThe conduct of inter-sectoral research using linked administrative health data requires a committedteam that is adequately resourced and has a set of clear, feasible objectives at the start. Guiding principles include: maximization of sectoral participation by including single-jurisdictionexpertise and making the most inclusive data decisions; use of living documents that track all datadecisions and careful consideration about data quality and availability differences. Inter-sectoral research requires a good understanding of the local healthcare system and othercontextual issues for appropriate interpretation of observed differences.

Background As part of a broader study to improve the capacity for advance care planning (ACP) in primary healthcare settings, the research team set out to develop and validate a computerized algorithm to help primary care physicians identify individuals at risk of death, and also carried out focus groups and interviews with relevant stakeholder groups. Interviews with patients and family caregivers were carried out in parallel to algorithm development and validation to examine (1) views on early identification of individuals at risk of deteriorating health or dying; (2) views on the use of a computerized algorithm for early identification; and (3) preferences and challenges for ACP. Methods Fourteen participants were recruited from two Canadian provinces. Participants included individuals aged 65 and older with declining health and self-identified caregivers of individuals aged 65 and older with declining health. Semi-structured interviews were conducted via telephone. A qualitative descriptive analytic approach was employed, which focused on summarizing and describing the informational contents of the data. Results Participants supported the early identification of patients at risk of deteriorating health or dying. Early identification was viewed as conducive to planning not only for death, but for the remainder of life. Participants were also supportive of the use of a computerized algorithm to assist with early identification, although limitations were recognized. While participants felt that having family physicians assume responsibility for early identification and ACP was appropriate, questions arose around feasibility, including whether family physicians have sufficient time for ACP. Preferences related to the content of and approach to ACP discussions were highly individualized. Required supports during ACP include informational and emotional supports. Conclusions This work supports the role of primary care providers in the early identification of individuals at risk of deteriorating health or death and the process of ACP. To improve ACP capacity in primary healthcare settings, compensation systems for primary care providers should be adjusted to ensure appropriate compensation and to accommodate longer ACP appointments. Additional resources and more established links to community organizations and services will also be required to facilitate referrals to relevant community services as part of the ACP process.

Background Middle managers are given scant attention in the implementation literature in health care, where the focus is on senior leaders and frontline clinicians. Aims To empirically examine the role of middle managers relevant to innovation implementation and how middle managers experience the implementation process. Methods A qualitative study was conducted using the methods of grounded theory. Data were collected through semistructured interviews with middle managers (N = 15) in Nova Scotia and New Brunswick, Canada. Participants were purposively sampled, based on their involvement in implementation initiatives and to obtain variation in manager characteristics. Data were collected and analyzed concurrently, using an inductive constant comparative approach. Data collection and analysis continued until theoretical saturation was reached. Results Middle managers see themselves as being responsible for making implementation happen in their programs and services. As a result, they carry out five roles related to implementation: planner, coordinator, facilitator, motivator, and evaluator. However, the data also revealed two determinants of middle managers' role in implementation, which they must negotiate to fulfill their specific implementation roles and activities: (1) They perform many other roles and responsibilities within their organizations, both clinical and managerial in nature, and (2) they have limited decision‐making power with respect to implementation and must work within the parameters set by upper levels of the organization. Linking Evidence to Action Middle managers play an important role in translating adoption decisions into on‐the‐ground implementation. Optimizing their capacity to fulfill this role may be key to improving innovation implementation in healthcare organizations.

Objective To identify and illuminate influences on middle managers’ commitment to innovation implementation. Methods A qualitative study was conducted, employing the methods of grounded theory. Semi-structured interviews were used to collect data from middle managers (n = 15) in Nova Scotia and New Brunswick, Canada. Data were collected and analysed concurrently, using an inductive constant comparative approach. Data collection and analysis continued until theoretical saturation was reached. Results The data revealed middle managers contemplate two central issues in terms of their commitment to implementation, that is whether or not they fully engage in and support the implementation of a particular innovation. These issues are (1) ease of implementation and (2) potential benefit for patients. Middle managers’ views and expectations related to ease of implementation are influenced by available resources, fit with setting, and stakeholder buy-in. Their views on patient benefit are influenced by external evidence of benefit and local gaps in care. Conclusions These findings provide further insight into the factors that influence middle managers’ commitment to innovation implementation, and how middle managers consider these factors in the context of their work settings.

This study sought to develop frailty “identification rules” using population-based health administrative data that can be readily applied across jurisdictions for living and deceased persons. Three frailty identification rules were developed based on accepted definitions of frailty, markers of service utilization, and expert consultation, and were limited to variables within two common population-based administrative health databases: hospital discharge abstracts and physician claims data. These rules were used to identify persons with frailty from both decedent and living populations across five Canadian provinces. Participants included persons who had died and were aged 66 years or older at the time of death (British Columbia, Alberta, Ontario, Quebec, and Nova Scotia) and living persons 65 years or older (British Columbia, Alberta, Ontario, and Quebec). Descriptive statistics were computed for persons identified using each rule. The proportion of persons identified as frail ranged from 58.2-78.1 per cent (decedents) and 5.1-14.7 per cent (living persons).

Background One of the key conceptual challenges in advancing our understanding of how to more effectively sustain innovations in health care is the lack of clarity and agreement on what sustainability actually means. Several reviews have helped synthesize and clarify how researchers conceptualize and operationalize sustainability. In this study, we sought to identify how individuals who implement and/or sustain evidence-informed innovations in health care define sustainability. Methods We conducted in-depth, semi-structured interviews with implementation leaders and relevant staff involved in the implementation of evidence-based innovations relevant to cancer survivorship care (n = 27). An inductive approach, using constant comparative analysis, was used for analysis of interview transcripts and field notes. Results Participants described sustainability as an ongoing and dynamic process that incorporates three key concepts and four important conditions. The key concepts were: (1) continued capacity to deliver the innovation, (2) continued delivery of the innovation, and (3) continued receipt of benefits. The key conditions related to (2) and (3), and included: (2a) innovations must continue in the absence of the champion or person/team who introduced it and (3a) adaptation is critical to ensuring relevancy and fit, and thus to delivering the intended benefits. Conclusions Participants provided a nuanced view of sustainability, with both continued delivery and continued benefits only relevant under certain conditions. The findings reveal the interconnected elements of what sustainability means in practice, providing a unique and important perspective to the academic literature.

ObjectiveAs polypharmacy increases, so does the complexity of prescribing, dispensing and consuming medicines. Medication safety is typically framed as the avoidance of harm, achievable through adherence to policies, guidelines and operational standards. Automation, robotics and technologies are positioned as key players in the elimination of medication error in the face of escalating demand, despite limited research illuminating how these innovations are taken up, used and adapted in practice. We explore how ‘safety’ is constructed and accomplished in community pharmacies in the context of polypharmacy.Design and settingIn-depth ethnographic case study across four community pharmacies in England (December 2017–July 2019). Data collection entailed 140 hours participant observation and 19 in-depth interviews. Practice theory informed the analysis.Participants33 pharmacy staff (counter staff, technicians, dispensers, pharmacists).ResultsIn their working practices related to polypharmacy, staff used the term ‘safety’ in explanations of why and how they were doing things in particular ways. We present three interlinked analytic themes within an overarching narrative of care: caring for the technology; caring for each other; and caring for the patient. Our study revealed a paradox: polypharmacy was visible, pervasive and productive of numerous routines, but rarely discussed as a safety concern per se. Safety meant ensuring medicines were dispensed as prescribed, and correcting errors pertaining to individual drugs through the clinical check. Pharmacy staff did not actively challenge polypharmacy, even when the volume of medicines dispensed might indicate ‘high risk' polypharmacy, locating the responsibility for polypharmacy with prescribing clinicians.Conclusion‘Safety’ in the performance of practices relating to polypharmacy was not a fixed, defined notion, but an ongoing, collaborative accomplishment, emerging within an organisational narrative of ‘care’. Despite meticulous attention to ‘safety’, carefully guarded professional boundaries meant that addressing polypharmacy per se in the context of community pharmacy was beyond reach.

ObjectivesMoving innovations into healthcare organisations to increase positive health outcomes remains a significant challenge. Even when knowledge and tools are adopted, they often fail to become integrated into the long-term routines of organisations. The objective of this study was to identify factors and processes influencing the sustainability of innovations in cancer survivorship care.DesignQualitative study using semistructured, in-depth interviews, informed by grounded theory. Data were collected and analysed concurrently using constant comparative analysis.Setting25 cancer survivorship innovations based in six Canadian provinces.ParticipantsTwenty-seven implementation leaders and relevant staff from across Canada involved in the implementation of innovations in cancer survivorship.ResultsThe findings were categorised according to determinants, processes and implementation outcomes, and whether a factor was necessary to sustainability, or important but not necessary. Seven determinants, six processes and three implementation outcomes were perceived to influence sustainability. The necessary determinants were (1) management support; (2) organisational and system-level priorities; and (3) key people and expertise. Necessary processes were (4) innovation adaptation; (5) stakeholder engagement; and (6) ongoing education and training. The only necessary implementation outcome was (7) widespread staff and organisational buy-in for the innovation.ConclusionsFactors influencing the sustainability of cancer survivorship innovations exist across multiple levels of the health system and are often interdependent. Study findings may be used by implementation teams to plan for sustainability from the beginning of innovation adoption initiatives.

Background Health care delivery and outcomes can be improved by using innovations (i.e., new ideas, technologies, and practices) supported by scientific evidence. However, scientific evidence may not be the foremost factor in adoption decisions and is rarely sufficient. The objective of this study was to examine the role of scientific evidence in decisions to adopt complex innovations in cancer care. Methods Using an explanatory, multiple case study design, we examined the adoption of complex innovations in five purposively sampled cases in Nova Scotia, Canada. Data were collected via documents and key informant interviews. Data analysis involved an in-depth analysis of each case, followed by a cross-case analysis to develop theoretically informed, generalizable knowledge on the role of scientific evidence in innovation adoption that may be applied to similar settings and contexts. Results The analyses identified key concepts alongside important caveats and considerations. Key concepts were (1) scientific evidence underpinned the adoption process, (2) evidence from multiple sources informed decision-making, (3) decision-makers considered three key issues when making decisions, and (4) champions were essential to eventual adoption. Caveats and considerations related to the presence of urgent problems and short-term financial pressures and minimizing risk. Conclusions The findings revealed the different types of issues decision-makers consider while making these decisions and why different sources of evidence are needed in these processes. Future research should examine how different types of evidence are legitimized and why some types are prioritized over others. Electronic supplementary material The online version of this article (10.1186/s13012-019-0859-5) contains supplementary material, which is available to authorized users.

IntroductionBreast cancer survivors are at risk for late and ongoing problems including cancer recurrence and late effects of treatment. Lack of access to quality follow-up care may affect later mortality, morbidity, and quality of life. This study examines variation in utilization of guideline-based follow-up care separately for four Canadian provinces. Objectives and ApproachFor our retrospective population-based cohort study of breast cancer survivors diagnosed from 2007 to 2010 in British Columbia (BC), 2007-2011 in Manitoba (MB), 2007-2010 in Ontario (ON), and 2007-2012 in Nova Scotia (NS), we linked provincial cancer registries, clinical and health administrative databases, and followed cases alive at 30 months post-diagnosis to five years from diagnosis. For each province, we calculated percent adherence, overuse, and underuse of recommended follow-up care, including surveillance for recurrent and new cancer, surveillance for late effects, and general preventive care. We also examined variation among provinces and over time. ResultsSurvivor numbers were 23,700 (ON), 9493 (BC), 2688 (MB), and 2735 (NS). Annual oncologist visit guideline compliance varied provincially (e.g. Year 2 ON=32.7%, BC=15.0%). For most provinces and follow-up years, the majority of survivors had fewer oncologist visits than recommended. However, survivors had additional annual breast cancer-related visits to a primary care provider. Surveillance breast imaging guideline compliance was high (e.g. Year 2, ON=81.1%, MB=72.0%, NS=52.8%, BC =49.7%), with rates declining in ON and MB (to approximately 64%), but increasing in NS and BC (to approximately 58%) by Year 5. Overuse of breast imaging was identified in NS (9.1%-20.7% overuse in follow-up years 2-5). As per the guideline, 72.9%-79.7% (Years 2-5) of BC survivors had no imaging for metastastic disease, highest among all provinces. Conclusion/ImplicationsProvincial and temporal variations in guideline adherence were identified. Patterns differed by guideline, and both overuse and underuse were observed. These results point to opportunities to improve survivor care and efficiencies in care delivery. In particular, regular care with a primary care physician has been shown to improve follow-up care.

IntroductionBreast cancer screening is intended to identify cancer in early stages when prognosis is better and treatments less invasive. Objectives and ApproachWe describe Canadian inter- and intra-provincial variation in the percentage of screen-detected cases and identify factors related to having a screen-detected versus a non-screen detected breast cancer. Breast cancers diagnosed from 2004/7 to 2010/11/12 in 5 Canadian provinces were included. Standard provincial datasets were created using screening program and claims data. A common algorithm (Alberta, Ontario) or variable from the screening dataset (British Columbia, Manitoba, Nova Scotia) was used to identify the mode of diagnosis (screening versus not). Relationship between screen-detected cancer and several demographic, clinical and healthcare utilization factors were explored. ResultsThe percentage of screen-detected breast cancers varied from 25 to 40 percent across provinces; it ranged 43 to 51 percent for those aged 50-69. Within provinces, the percentage of screen-detected cancers varied across regional health authorities by a low of 1\% to a high of 33\%. Urban residence was positively associated with screen-detection in some provinces and negatively in others. Women in the lowest neighborhood income quintile had the smallest proportion of screen-detected cancers; the absolute difference from those in the highest quintiles ranged from 3.3-11.5\% across provinces. High continuity of care with a usual primary care provider was positively associated with having a screen-detected cancer compared to those with no usual care provider. Conclusion/ImplicationsThe proportion of screen-detected breast cancers varied significantly across and within provinces suggesting geographic variability in access to screening services. Variation across provinces in terms of factors associated with screen-detected breast cancer also likely reflect access issues. The positive association of high continuity of care with screen-detection in all provinces suggests that regular care with a primary care physician is an important factor in improving screening rates and detection.

IntroductionBreast cancer survivors are at risk for late and ongoing problems including cancer recurrence and late effects of treatment. Vulnerable groups may not enjoy equitable access to quality follow-up care. This study examines utilization of guideline-based follow-up care among vulnerable subpopulations in four Canadian provinces. Objectives and ApproachFor vulnerable groups of breast cancer survivors diagnosed from 2007-2010 in British Columbia (BC), 2007-2011 in Manitoba (MB), 2007-2010 in Ontario (ON), and 2007-2012 in Nova Scotia (NS), alive at 30 months post-diagnosis and followed for five years from diagnosis, we undertook a retrospective population-based cohort study linking cancer registries, clinical and health administrative databases. We calculated adherence to recommended follow-up care for surveillance of recurrent and new cancer, late effects, and general preventive care, and examined variation among provinces. Vulnerable groups were defined as those diagnosed at older ages, with lower income status, and/or who resided in rural area. ResultsSurvivor numbers were 23,700 (ON), 9493 (BC), 2688 (MB), and 2735 (NS). In Year 2, between 9.3% (BC) and 28.1% (ON) of survivors diagnosed aged 74+ years received annual breast cancer-related PCP or oncologist follow-up visits, a lower proportion than their younger-diagnosed counterparts; rates of surveillance breast imaging (between 34.2% (BC) and 68.6% (ON) in Year 2) were also lower than those diagnosed at younger ages. Those with incomes in the lowest 40\% did not have different rates of primary care physician and oncologist visits compared to the top 60%, nor did their utilization of surveillance imaging or imaging for metastatic disease differ. Guideline-adherent surveillance breast imaging was conducted on a higher proportion of urban than rural patients in all provinces. Conclusion/ImplicationsWhile area-level incomes do not appear to appreciably affect follow-up care, older age and rural residence resulted in differential access to care. These results suggest that there are gaps in provision of follow-up care that potentially can be addressed through system and practice-level change.

IntroductionA long breast cancer diagnostic process can affect patient anxiety and survival. Variations in the length of the diagnostic interval for similar patient presentations can indicate health system inequities and/or inefficiencies. Objectives and ApproachWe describe the breast cancer diagnostic interval across Canada and factors associated with its length. We studied breast cancer patients diagnosed from 2004/7 to 2010/11/12 in the Canadian provinces: British Columbia, Alberta, Manitoba, Ontario, and Nova Scotia. Using administrative data, we created parallel population-based, provincial-level datasets and ran common analyses. The diagnostic interval was defined from the screening mammogram to the diagnosis for screen-led and from the first referral/test ordering date to the diagnosis for diagnostic-led patients. Stratified by these two diagnostic routes, we describe the variation in the interval across provinces and report on the province-specific associations between the diagnostic interval and: patient age, comorbid disease burden, socioeconomic status combined with rural residence, and continuity of primary care while controlling for cancer stage. ResultsThe median diagnostic interval varied by 6 days (29 to 35 days) across provinces. Screen-led patients were diagnosed more quickly (median 2-12 days quicker). The 90th percentile diagnostic interval was 84-126 days longer in diagnostic-led patients. In the diagnostic-led group, increasing comorbid burden was consistently associated with longer diagnostic intervals and being >70 was associated with a shorter interval at the 90th percentile in Manitoba and Ontario. There was no evidence of a clear rural or low socioeconomic status effect and patients without a primary care physician had shorter intervals. In the screen-led group, patients age 40-49 and those in the medium or low income rural areas waited longer for a diagnosis. Conclusion/ImplicationsDiagnostic wait times differ across Canada and are variably associated with comorbidity, age, area-level socioeconomic status and rural residence. These results point to practice and system-level effects that warrant further study.

Measuring responses to a more unstable walking environment at the point-of-care may reveal clinically relevant strategies, particularly for rehabilitation. This study determined if temporal measures, center of pressure-derived measures, and force impulse measures can quantify responses to surface instability and correlate with clinical balance and mobility measures.Thirty-one unilateral amputees, 11 transfemoral and 20 transtibial, walked on level and soft ground while wearing pressure-sensing insoles. Foot-strike and foot-off center of pressure, center of pressure path, temporal, and force impulse variables were derived from F-Scan pressure-sensing insoles.Significant differences (P0.05) between level and soft ground were found for temporal and center of pressure path measures. Twenty regression models (R(2) ≤ 0.840), which related plantar-pressure-derived measures with clinical scores, consisted of nine variables. Stride time was in eight models; posterior deviations per stride in six models; mean CoP path velocity in five models; and anterior-posterior center of pressure path coefficient of variation, percent double-support time, and percent stance in four models.Center of pressure-derived parameters, particularly temporal and center of pressure path measures, can differentiate between level and soft ground walking for transfemoral and transtibial amputees. Center of pressure-derived parameters correlated with clinical measures of mobility and balance, explaining up to 84.0% of the variability. The number of posterior deviations per stride, mean CoP path velocity stride time, anterior-posterior center of pressure path coefficient of variation, percent double-support time, and percent stance were frequently related to clinical balance and mobility measures.

For people with lower extremity amputations, the decreased confidence and suboptimal gait associated with dynamic instability can negatively affect mobility and quality of life. Quantifying dynamic instability could enhance clinical decision making related to lower extremity prosthetics and inform future prosthetic research.To quantitatively examine gait adaptations in transfemoral amputees across various walking conditions.Cross-sectional study.Plantar-pressure data were collected from 11 individuals with unilateral transfemoral amputations using an in-shoe plantar-pressure measurement system while navigating rigid and soft ground, ramp, and stair conditions. Six parameters were examined: anterior-posterior and medial-lateral center-of-pressure direction changes, sensor cell loading frequency (cell triggering), maximum lateral force position, double support time, and stride time. Paired t-tests and analyses of variance were used to examine differences between limbs and walking conditions, respectively.Values for medial-lateral center-of-pressure direction change, sensor cell loading frequency, and double support time were significantly greater on the intact limb than the prosthetic limb. Significant differences between conditions occurred only for anterior-posterior center-of-pressure direction change and double support time on the prosthetic limb.Higher values on the intact limb suggest that it plays a key role in maintaining stability and optimizing body progression during different tasks. Differences between participants, limbs, and walking condition indicate parameter sensitivity to adaptive gait strategies.This plantar-pressure-based approach is a viable option for point-of-care evaluation of locomotor performance, across common various mobility tasks and activities of daily living. The information obtained could be valuable for prosthetic prescription and optimization of prosthetic fit and alignment, potentially improving mobility for prosthetic users with dynamic stability deficits.

This study investigated whether pelvis acceleration-derived parameters can differentiate between dynamic stability states for transtibial amputees during level (LG) and uneven ground (UG) walking. Correlations between these parameters and clinical balance and mobility measures were also investigated. A convenience sample of eleven individuals with unilateral transtibial amputation walked on LG and simulated UG while pelvis acceleration data were collected at 100Hz. Descriptive statistics, Fast Fourier Transform, ratio of even to odd harmonics, and maximum Lyapunov exponent measures were derived from acceleration data. Of the 26 pelvis acceleration measures, seven had a significant difference (p≤0.05) between LG and UG walking conditions. Seven distinct, stability-relevant measures appeared in at least one of the six regression models that correlated accelerometer-derived measures to Berg Balance Scale (BBS), Community Balance and Mobility Scale (CBMS), and Prosthesis Evaluation Questionnaire (PEQ) scores, explaining up to 100% of the variability in these measures. Of these seven measures, medial-lateral acceleration range was the most frequent model variable, appearing in four models. Anterior-posterior acceleration standard deviation and stride time appeared in three models. Pelvis acceleration-derived parameters were able to differentiate between LG and UG walking for transtibial amputees. UG walking provided the most relevant data for balance and mobility assessment. These results could translate to point of patient contact assessments using a wearable system such as a smartbelt or accelerometer-equipped smartphone.

RATIONALE, AIMS, AND OBJECTIVES Focusing on the implementation of clinical practice guidelines (CPGs) for the management of adult cancers, the objectives of this study were to (a) describe the intrinsic elements known to influence CPG use; (b) identify the ways in which CPGs are implemented; and (c) explore how CPG characteristics and contextual factors influence implementation and use. METHODS We conducted a sequential mixed methods study. First, we performed a content analysis of all CPGs developed and approved for the management of adult cancers in Nova Scotia, Canada, from 2005 to 2015. CPGs were examined for the presence of 22 elements known to influence CPG use. Next, we conducted semistructured interviews with CPG developers and end users. Participants were purposively sampled, based on the findings of the content analysis. All interviews were audiotaped and transcribed verbatim. Data were analysed by two researchers using the Framework Method. RESULTS CPGs (n = 20) demonstrated large variation with respect to elements shown to influence CPG use. For example, 85% included content related to individualization and objectives. Yet no CPGs (0%) had journal or patient versions; discussed the education, training, or competencies needed to deliver recommendations; contained an explicit statement on anticipated work changes, or on potential direct or productivity costs; or identified barriers or facilitators that might influence CPG adoption. Interview data from CPG developers (n = 4) and users (n = 6) revealed five themes related to CPG implementation and use: (a) lack of consistency in CPG development; (b) timing and nature of stakeholder engagement; (c) credibility of the CPG development process and final CPGs; (d) limited understanding of implementation as an active process; and (e) factors at organizational and system levels influence CPG implementation and use. CONCLUSIONS This mixed methods study provides complementary data that may help inform more effective CPG implementation efforts and optimize their use in practice.

BackgroundStrategies have been developed for use in primary care to identify patients at risk of declining health and dying, yet little is known about the perceptions of doing so or the broader implications and impacts.AimTo explore the acceptability and implications of using a primary care-based electronic medical record algorithm to help providers identify patients in their practice at risk of declining health and dying.Design and settingQualitative descriptive study in Ontario and Nova Scotia, Canada.MethodSix focus groups were conducted, supplemented by one-on-one interviews, with 29 healthcare providers, managers, and policymakers in primary care, palliative care, and geriatric care. Participants were purposively sampled to achieve maximal variation. Data were analysed using a constant comparative approach.ResultsSix themes were prevalent across the dataset: early identification is aligned with the values, aims, and positioning of primary care; providers have concerns about what to do after identification; how we communicate about the end of life requires change; early identification and subsequent conversations require an integrated team approach; for patients, early identification will have implications beyond medical care; and a public health approach is needed to optimise early identification and its impact.ConclusionStakeholders were much more concerned with how primary care providers would navigate the post-identification period than with early identification itself. Implications of early identification include the need for a team-based approach to identification and to engage broader communities to ensure people live and die well post-identification.

ObjectiveCanIMPACT is a multi-province Canadian research team funded to understand the interplay between primary and oncology breast cancer care. A first step was to describe current practice and inter/intra-provincial care variation across the care continuum using provincial administrative health data. Here we describe the inter-provincial process and analysis plans. ApproachOur multi-disciplinary team includes five Canadian provinces: British Columbia, Alberta, Manitoba, Ontario and Nova Scotia. Cohorts consist of all breast cancers diagnosed from 2007 to at least 2011 in each of the five provinces. Common databases include cancer registries, census area-level income and rurality, outpatient physician claims, ambulatory care and inpatient hospitalizations. Other databases with laboratory, pharmacy, emergency services, and immigration data were available in some provinces. Common data elements across provincial datasets were identified, and a standardized methodology was developed. ResultsCommon data processing and analysis plans were finalized over 24 months; provinces refined details as per local context while maximizing methodological comparability. Basic descriptive analyses plus 18 phase-specific and 3 longitudinal analyses have been planned. Six plans for the diagnostic phase focus on identifying modifiable disparities in access and outcomes; 8 plans for the treatment phase focus on variation in chemotherapy treatment patterns, quality/safety, and utilization of primary care services; 4 plans for the survivorship phase focus on adherence to guidelines for follow-up breast cancer care, other chronic diseases and preventive care; 3 longitudinal analyses assess factors related to changes in utilization of chronic disease services over the cancer care continuum. ConclusionsWe have shown it is feasible to develop and standardize data processing and analyses across multiple provinces to address important cancer care questions across the continuum. This work will inform comparisons and improvements in Canadian cancer care. This effort has also helped increase research capacity in health services research.

Oncologists have traditionally been responsible for providing routine follow-up care for cancer survivors, in recent years, however, primary care providers (pcps) are taking a greater role in care during the follow-up period. In the present study, we used a longitudinal multi-province retrospective cohort study to examine how primary care and specialist care intersect in the delivery of breast cancer follow-up care. Various databases (registry, clinical, and administrative) were linked in each of four provinces: British Columbia, Manitoba, Ontario, and Nova Scotia. Population-based cohorts of breast cancer survivors were identified in each province. Physician visits were identified using billings or claims data and were classified as visits to primary care (total, breast cancer&ndash, specific, and other), oncology (medical oncology, radiation oncology, and surgery), and other specialties. The mean numbers of visits by physician type and specialty, or by combinations thereof, were examined. The mean numbers of visits for each follow-up year were also examined by physician type. The results showed that many women (>64%) in each province received care from both primary care and oncology providers during the follow-up period. The mean number of breast cancer&ndash, specific visits to primary care and visits to oncology declined with each follow-up year. Interprovincial variations were observed, with greater surgeon follow-up in Nova Scotia and greater primary care follow-up in British Columbia. Provincial differences could reflect variations in policies and recommendations, relevant initiatives, and resources or infrastructure to support pcp-led follow-up care. Optimizing the role of pcps in breast cancer follow-up care might require strategies to change attitudes about pcp-led follow-up and to better support pcps in providing survivorship care.

Patient engagement (PE) is not well defined and little guidance is available to those attempting to employ PE in decision-making relevant to health system improvement. After completing a 2-year PE project, overseen by an Advisory Committee, our objectives were: 1) to evaluate how effectively the project team engaged the Advisory Committee, 2) to examine how Advisory Committee members perceived PE and their role in PE, and 3) to identify barriers and facilitators to PE in order to improve future efforts. Five members of the Advisory Committee completed semi-structured interviews post-project about their experiences. Thematic analysis identified four themes: the approach, participant contributions, participant understanding of PE, and barriers and facilitators to PE. The use of a committee approach was considered beneficial, providing an opportunity to discuss the project in depth, contributing to relationship building, and helping move the project forward. The social aspect of the committee approach was an important part of the engagement process. Participants felt they contributed primarily by participating in discussion, yet could not identify specific contributions they had made. All participants agreed that the experience was meaningful but not profound with regard to how it would impact their engagement, or their engagement of others, in the future. Although experiences were highly subjective, this study suggests that the act of participating in PE has meaning in and of itself to those involved, independent of the activities and/or outcomes of that participation, reflecting a broader public value that PE is an important component of transparent, accountable health systems.

Background Because surgeons are the main gatekeepers to oncology services, understanding how they make decisions related to referral for adjuvant therapies is important to optimize referral rates and use of oncology services for patients with potentially curable disease. We examined decision-making by surgeons related to referral to oncology services for patients having undergone curative-intent surgery for non-small-cell lung, breast or colorectal cancer. Methods We conducted a qualitative study, whose design was guided by the principles of grounded theory. Semi-structured interviews were held with 29 surgeons who performed non-small-cell lung, breast or colorectal cancer surgery in the province of Nova Scotia. Data were collected and analyzed concurrently. Analysis involved an inductive, grounded approach using constant comparative analysis. Data collection and analysis continued until theoretical saturation was reached. Results Seven factors influenced the surgeons' decision-making related to referral to oncology services: indications and contraindications for therapy; patients' beliefs and preferences; a belief that oncologists are the experts; knowledge of local standards of care; consultation with oncology colleagues; navigating patient logistics (e.g., lodging, caregiving responsibilities, insurance coverage); and system resources and capacity. Interpretation Our study's findings provide a novel understanding of how surgeons make decisions about oncology referral and point to potential areas for intervention to promote referral to oncology services for patients for whom adjuvant therapy is recommended.

The purpose of this study was to examine colorectal cancer (CRC) follow-up care in Nova Scotia, Canada. More specifically, the objectives were to describe adherence to two elements of follow-up guidelines (colonoscopies and physician visits) and to identify factors associated with receiving at least guideline-recommended care.All patients with stage II or III CRC undergoing curative-intent surgery in Nova Scotia, Canada, were identified through the provincial cancer registry and anonymously linked to additional administrative health databases. For a 3-year follow-up period, beginning 1 year after the diagnosis date, descriptive statistics were calculated for physician visits and colonoscopies. Factors associated with receiving at least guideline-recommended care were identified using logistic regression.Most patients received follow-up care from multiple physician specialties. In year 3, 58.1% of patients received oncologist follow-up care. Guideline adherence for colonoscopies was 52.4%, whereas guideline adherence for physician visits decreased from 41.9% to 25.4%. Receipt of at least guideline-recommended care was inversely associated with age and comorbidity for colonoscopy and inversely associated with age for physician visits.Receipt of follow-up care from oncologists and primary care physicians, prolonged oncologist care, and receipt of care inconsistent with guideline recommendations suggest there may be potential issues with inefficient use of cancer system resources and integration of guidelines into follow-up care practices in Nova Scotia. Transitioning routine follow-up to primary care could potentially increase guideline adherence by improving access to and continuity of care. CRC may be well suited to targeted knowledge translation strategies to improve guideline adherence.

Individuals diagnosed with cancer close to death have low access to enrollment in palliative care programs. The purpose of this literature review was to assess the usefulness of pre-diagnostic comorbidity and healthcare utilization as indicators of late-stage colorectal cancer (CRC) diagnosis, to help with early identification of individuals who may benefit from palliative care.A literature search was conducted in relevant databases using title/abstract terms which included "cancer," "stage," "diagnosis," "determinants," "predictors," and "associated." Included studies examined whether comorbidity and/or healthcare utilization had an impact on the stage at which CRC was diagnosed. A standardized data abstraction form was used to assess the eligibility of each study. Thirteen articles were included in the literature review. These studies were assessed and synthesized using qualitative methodology.We found much heterogeneity among study variables. The findings of this literature review point to the presence of comorbidity and non-emergent healthcare utilization as having no association with late-stage diagnosis. Conversely, emergency room presentation (ERP) was associated with late-stage diagnosis.The results of this literature review did not find strong evidence to suggest that comorbidity and healthcare utilization are potential indicators of late-stage diagnosis. However, ERP may be useful as a flag for consideration of prompt referral to palliative care. Additional research is required to identify potential indicators of late-stage diagnosis that may be available in administrative databases, particularly in the area of healthcare utilization.

Background: Substantial gains could be made in reducing the cancer burden if current scientific evidence was applied in practice. The World Health Organization estimates that, worldwide, one-third of cancer cases could be prevented and another one-third cured if evidence was consistently implemented and sustained in cancer care. However, moving evidence-based interventions into care has proven a significant challenge. Even when interventions are put into practice, they often fail to become integrated into the long-term routines of organizations. This poor sustainability means many patients do not benefit from the best care possible. There is little empirical data on the factors that influence the sustainability of interventions in clinical settings. Aim: To identify the determinants of, and explore the processes that facilitate, sustainability of interventions in cancer care survivorship. Sustainability was defined as the continued use of an intervention and its associated components and/or the continued achievement of the intended benefits after the initial funding or support period. Methods: We first conducted an environmental scan to identify interventions in cancer survivorship care implemented in Canada. This was followed by a literature review to ascertain the evidence base for each intervention and identify those meeting the US National Cancer Institute's criteria for evidence-based interventions. We then recruited key individuals relevant to the evidence-based interventions for semistructured in-depth interviews to explore issues related to their sustainability. Interview data are being analyzed through an inductive grounded theory approach using constant comparative analysis. Results: Twenty-seven individuals participated in the interviews. Preliminary findings reveal five factors that influenced whether, and the extent to which, interventions were sustained in cancer survivorship care. Participants emphasized (1) access to sufficient resources and funding is critical to sustaining interventions after the initial funding period. The ability of a team or organization to (2) evaluate a new intervention and demonstrate its quality and usefulness was often perceived as necessary to obtain continued funding as well as ongoing buy in and support from key stakeholders. In addition, the (3) extent to which the intervention can be adapted, (4) support of senior management, and (5) existence of an on-the-ground champion to continuously promote, adapt, lead, and spread the intervention were perceived as important factors that contribute to an intervention's sustained use. Conclusion: Research into determinants and processes of sustainability is critical to ensure we plan and act in ways that maximize the sustained use of interventions shown to benefit patients and our cancer systems. Issues related to evaluation, adaptability, and ongoing moral and material supports should be considered before, during, and after implementation efforts.

Background While efforts to improve cancer outcomes have typically focused on improving quality of care, recently, a growing emphasis has been placed on timely access to quality cancer care. This retrospective cohort study examines, at a population level, the relationship between quality and timeliness of colorectal cancer (CRC) care in a single Canadian province (Nova Scotia). Through the provincial cancer registry, we identified all residents diagnosed with invasive CRC between 2001 and 2005 that underwent a non-emergent resection. Using anonymized administrative databases that are individually linked at the patient level, we obtained clinicodemographic, diagnostic, and treatment event data. Selected charts were reviewed to ensure completeness of chemotherapy data. Performance on six quality indicators and the percentage of patients achieving wait-time benchmarks for diagnosis, surgery, and adjuvant therapy were calculated. The relationship between quality indicators and wait-time benchmarks was examined using logistic regression. Results Where an association was identified, patients who received ‘higher quality care’ had longer wait times. Individuals who received a complete preoperative colonoscopy were less likely to meet benchmarks for time from presentation to diagnosis and from diagnosis to surgery. Those who received an appropriate radiation oncology consultation were less likely to meet benchmarks for time from diagnosis to surgery and from surgery to adjuvant therapy. Conclusions As governments and other organizations move forward with strategies to reduce wait times, they must also focus on how to define and monitor quality care, and consider the relationship between these two dimensions of health care. Similarly, when developing quality improvement initiatives, the impact on resource utilization and potential to create longer waits for care must be considered.

Background Non-small cell lung cancer, breast cancer, and colorectal cancer are commonly diagnosed cancers in Canada. Patients diagnosed with early-stage non-small cell lung, breast, or colorectal cancer represent potentially curable populations. For these patients, surgery is the primary mode of treatment, with (neo)adjuvant therapies (e.g., chemotherapy, radiotherapy) recommended according to disease stage. Data from our research in Nova Scotia, as well as others’, demonstrate that a substantial proportion of non-small cell lung cancer and colorectal cancer patients, for whom practice guidelines recommend (neo)adjuvant therapy, are not referred for an oncologist consultation. Conversely, surveillance data and clinical experience suggest that breast cancer patients have much higher referral rates. Since surgery is the primary treatment, the surgeon plays a major role in referring patients to oncologists. Thus, an improved understanding of how surgeons make decisions related to oncology services is important to developing strategies to optimize referral rates. Few studies have examined decision making for (neo)adjuvant therapy from the perspective of the cancer surgeon. This study will use qualitative methods to examine decision-making processes related to referral to oncology services for individuals diagnosed with potentially curable non-small cell lung, breast, or colorectal cancer. Methods A qualitative study will be conducted, guided by the principles of grounded theory. The study design is informed by our ongoing research, as well as a model of access to health services. The method of data collection will be in-depth, semi structured interviews. We will attempt to recruit all lung, breast, and/or colorectal cancer surgeons in Nova Scotia (n ≈ 42), with the aim of interviewing a minimum of 34 surgeons. Interviews will be audiotaped and transcribed verbatim. Data will be collected and analyzed concurrently, with two investigators independently coding and analyzing the data. Analysis will involve an inductive, grounded approach using constant comparative analysis. Discussion The primary outcomes will be (1) identification of the patient, surgeon, institutional, and health-system factors that influence surgeons’ decisions to refer non-small cell lung, breast, and colorectal cancer patients to oncology services when consideration for (neo)adjuvant therapy is recommended and (2) identification of potential strategies that could optimize referral to oncology for appropriate individuals.

A 3 × 4 electrode array was placed over each of seven muscles and surface electromyography (sEMG) data were collected during isometric contractions. For each array, nine bipolar electrode pairs were formed off-line and sEMG parameters were calculated and evaluated based on repeatability across trials and comparison to an anatomically placed electrode pair. The use of time-domain parameters for the selection of an electrode pair from within a grid-like array may improve upon existing electrode placement methodologies.

Background Colorectal cancer (CRC) is the third most commonly diagnosed cancer in Canada and accounts for 11.9% of all cancer-related mortality. Fortunately, previous studies have provided evidence of improved outcomes from access to timely and appropriate health services along the disease trajectory in CRC. As a result, the CIHR/CCNS Team in Access to Colorectal Cancer Services in Nova Scotia (Team ACCESS) was created to build colorectal cancer (CRC) research capacity in Nova Scotia (NS) and to study access to and quality of CRC services along the entire continuum of cancer care. Objectives The objectives of this paper are to: 1) provide a detailed description of the methodologies employed across the various studies being conducted by Team ACCESS; 2) demonstrate how administrative health data can be used to evaluate access and quality in CRC services; and 3) provide an example of an interdisciplinary team approach to addressing health service delivery issues. Methods All patients diagnosed with CRC in NS between 2001 and 2005 were identified through the Nova Scotia Cancer Registry (NSCR) and staged using the Collaborative Stage Data Collection System. Using administrative databases that were linked at the patient level, Team ACCESS created a retrospective longitudinal cohort with comprehensive demographic, clinical, and healthcare utilization data. These data were used to examine access to and quality of CRC services in NS, as well as factors affecting access to and quality of care, at various transition points along the continuum of care. Team ACCESS has also implemented integrated knowledge translation strategies targeting policy- and decision- makers. Discussion The development of Team ACCESS represents a unique approach to CRC research. We anticipate that the skills, tools, and knowledge generated from our work will also advance the study of other cancer disease sites in NS. Given the increasing prevalence of cancer, and with national and provincial funding agencies promoting collaborative research through increased funding for research team development, the work carried out by Team ACCESS is important in the Canadian context and exemplifies how a team approach is essential to comprehensively addressing issues surrounding not only cancer, but other chronic diseases in Canada.

Orientation sensors containing magnetometers use the earth's magnetic field as a reference. Ferromagnetic objects may distort this magnetic field, leading to inaccurate orientation output. We explored the viability of these orientation sensors for motion analysis in an assistive mobility device rehabilitative setting. We attached two MTx orientation sensors (XSens; Enschade, the Netherlands), connected to the XBus Master data collection unit (XSens), to a plastic frame such that the relative angle between sensors was constant. We then moved a series of mobility devices in proximity to the plastic frame: two knee-ankle-foot orthoses (aluminum, stainless steel), one ankle-foot orthosis, two transtibial prostheses (exoskeletal, endoskeletal), two walkers (standard, Challenger Low Wide [Evolution Technologies; Port Coquitlam, Canada]), and two wheelchairs (Tango [OrthoFab; Quebec City, Canada], GTi [Quickie; Phoenix, Arizona]). For each mobility device, we calculated the average difference in relative angle between the baseline and peak angles for each of five trials. Errors ranged from less than 0.10 to 35.29 degrees, depending on the mobility device and frame positioning near the device. This demonstrated the large errors that can occur when magnetometer-based orientation sensors with mobility devices are used. While strategic orientation sensor placement on some mobility devices can minimize these errors to an acceptable level, testing protocols should be implemented to verify orientation sensor accuracy for these applications.

5 Background: CanIMPACT is a multi-provincial Canadian research team funded to identify and address key issues faced by cancer patients and providers at the intersection of primary and specialist oncology care. Canada has national healthcare standards, but provincial/territorial healthcare delivery systems. One facet will use administrative data from the population-based, publicly-funded healthcare system to evaluate issues during pre-diagnosis, treatment, and post-treatment survivorship for breast cancer patients. For the survivorship phase, we aim to conduct the following analyses and compare across provinces: 1) Utilization of physician services overall and by specialty, including oncologists, non-oncology specialists, and primary care; 2) Assessment of adherence to ASCO and Canadian follow-up guideline for breast cancer care, use of surveillance breast imaging, and metastatic investigations; 3) Assessment of adherence to recommended care of chronic illness and preventive care; 4) Quantification of the cost of follow-up overall and by specialty; 5) Comparison of inter- and intra-provincial variation for all outcomes by health administrative region and for vulnerable groups (age ≥ 75 at diagnosis, northern/rural/remote, low income, immigrants), and examine the effect of continuity of primary care and chronic disease on post-treatment care. Methods: Patients will be identified from provincial cancer registries and linked to data extracted from: outpatient physician service claims, hospital inpatient and outpatient data, and cancer facility medical records. Results: Participating provinces have finalized the core questions and detailed protocols, and assessed data comparability. They are in the process of obtaining the required ethics and data access approvals, and data acquisition for processing and analysis. Conclusions: Results will address existing information gaps that can be used to improve transition and care across the cancer care trajectory. Importantly, results will be combined with those of a CanIMPACT qualitative study to inform design of a pragmatic randomized trial focused on improving coordination and quality of care.

Background Our prior population-based research in Nova Scotia, Canada, demonstrated ‘gaps’ in referral practices for oncology patients with potentially curable disease. The objectives of this study were to examine surgeon decision-making related to referral to oncology services for potentially curable non-small-cell lung, breast, or colorectal cancer patients, and to identify the specific factors that influence their decision to refer (or not to refer).

6064 Background: Although CPGs recommend adjuvant chemotherapy (aCT) for stage IIB/III colon and aCT/radiation for stage II/III rectal cancer, population-based data on adherence and reasons for non...