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Background: Transitioning low-risk cancer survivors back to their primary care provider (PCP) has been shown to be safe but the effect on health system resources and costs has not been examined. Methods: A Well Follow-Up Care Initiative (WFCI) was implemented in the publicly funded health system. Low-risk breast cancer (BC) survivors in the WFCI intervention group were transitioned from oncologist-led cancer clinics to PCPs. We compared health system costs ($2,014 in Canadian dollars) and resource utilization in this intervention group with that in propensity-score–matched nontransitioned BC survivors (ie, controls) diagnosed in the same year, with similar disease profile and patient characteristics using publicly funded administrative databases. Results: A total of 2,324 BC survivors from the WFCI intervention group were 1:1 matched to controls and observed for 25 months. Compared with controls, survivors in the intervention group incurred a similar number of PCP visits (6.9 v 7.5) and fewer oncologist visits (0.3 v 1.2) per person-year. Fewer survivors in the intervention group (20.1%) were hospitalized than in the control group (24.4%). There were no differences in emergency visits. More survivors in the intervention group had mammograms (82.6% v 73.1%), but other diagnostic tests were less frequent. There was a 39.3% reduction in overall mean annual costs ($6,575 v $10,832) and a 22.1% reduction in overall median annual costs ($2,261 v $2,903). Overall survival in the intervention group was not worse than controls. Conclusion: Transitioning low-risk BC survivors to PCPs was associated with lower health system resource use and a lower annual cost per patient than matched controls. The WFCI model represents a reasonable approach at the population level to delivering quality care for low-risk BC survivors that seems to be cost effective.

To test the hypothesis that newborn infants cared for in hospitals with greater utilization of neonatal intensive care experienced fewer postdischarge adverse events.We developed 3 retrospective population-based cohorts of Texas Medicaid insured singletons born in 2010-2014 (very low birth weight [VLBW n = 11 139], late preterm [n = 57 509], and non-preterm [n = 664 447]) who received care in higher volume hospitals with level III/IV neonatal intensive care units (NICUs). Measures of NICU care were hospital-level risk adjusted NICU admission rates, special care days (days of nonroutine care) per infant, and the percent of intensive (highest billable care code) special care days. The units of analysis were hospitals (n = 80) and the primary outcome was an adverse event, (defined as admission, emergency department visit, or death) within 30 days postdischarge.Higher use of NICU care at a hospital level was not associated with lower postdischarge 30-day adverse event. Infants cared for in hospitals with above vs below median special care day rates experienced slightly higher postdischarge adverse event per 100 infants (VLBW: 14.01 [95% CI 12.74-15.27] vs 11.84 [10.52-13.16], P .05; late preterm: 7.33 [6.68-7.97] vs 6.28 [5.87-6.69], P .01; non-preterm: 4.47 [4.17-4.76] vs 3.97 [3.75-4.18], P .01). Weak positive associations (Pearson correlations of 0.31-0.37, P .01) were observed for adverse event with special care days; in no instance was a negative association observed between NICU utilization and adverse event.Higher utilization of NICU care was not associated with lower rates of short-term events suggesting that there may be opportunities to safely decrease admission rates and length of NICU stays.

Clostridium difficile infection (CDI) recurs in ∼20% of patients. Prior studies indicated that antibody responses directed against the C. difficile toxins A and B were potentially associated with lower risk of recurrent CDI. Here we tested the hypothesis that circulating anti-toxin IgG antibody levels associate with reduced risk of recurrent CDI. A cohort study with prospective enrollment and retrospective data abstraction examined antibody levels in 275 adult patients at the University of Michigan with CDI. We developed an enzyme linked immunosorbent assay to detect IgG antibodies against toxin A and toxin B in sera obtained at the time of diagnosis. Logistic regression examined the relationship between antibody levels and recurrence, and sensitivity tests evaluated for follow-up and survivor biases, history of CDI, and PCR ribotype. Follow-up data were available for 174 subjects, of whom 36 (20.7%) had recurrence. Comparing antibody levels vs. recurrence and CDI history, anti-toxin A levels were similar, while anti-toxin B levels had a greater range of values. In unadjusted analysis, detection of anti-toxin A antibodies, but not anti-toxin B antibodies, associated with an increased risk of recurrence (OR 2.71 [1.06, 8.37], P = .053). Adjusting for confounders weakened this association. The results were the same in sensitivity analyses. We observed a borderline increased risk of recurrence in patients positive for anti-toxin A antibodies, and sensitivity analyses showed this was not simply a reflection of prior exposure status. Future studies are needed to assess how neutralizing antibody or levels after treatment associate with recurrence.

Breast cancer is detected through screening or through signs and symptoms. In Canada, mammograms for breast cancer screening are offered in organized programs or independently (opportunistic screening). Province of Ontario breast Diagnostic Assessment Units (DAUs) are facility-based programs that provide coordinated breast cancer diagnostic services, as opposed to usual care, in which the primary care provider arranges the tests and consultations. This study describes breast cancer detection method, diagnostic interval and DAU use across Ontario.The study cohort consisted of 6898 women with invasive breast cancer diagnosed in 2011. We used the Ontario Cancer Registry linked to administrative health care databases. We determined the detection method using the Ontario Breast Screening Program (OBSP) data and physician claims. The diagnostic interval was the time between the initial screen, specialist referral or first diagnostic test and the cancer diagnosis. The diagnostic route (whether through DAU or usual care) was determined based on the OBSP records and biopsy or surgery location. We mapped the diagnostic interval and DAU coverage geographically by women's residence.In 2011, 36% of Ontario breast cancer patients were screen-detected, with a 48% rate among those aged 50 to 69. The provincial median diagnostic interval was 32 days, with county medians ranging from 15 to 65 days. Provincially, 48.4% were diagnosed at a DAU, and this ranged from zero to 100% across counties.The screening detection rate in age-eligible breast cancer patients was lower than published population-wide screening rates. Geographic mapping of the diagnostic interval and DAU use reveals regional variations in cancer diagnostic care that need to be addressed.Le cancer du sein est détecté soit par un examen de dépistage, soit à l’aide de signes et symptômes. Au Canada, les mammographies pour le dépistage du cancer du sein sont offertes dans le cadre de programmes organisés ainsi qu'en contexte indépendant (dépistage opportuniste). Les unités d’évaluation diagnostique (UED) de la province de l’Ontario sont des programmes en établissement qui fournissent des services diagnostiques coordonnés pour le cancer du sein, à la différence des soins habituels où le fournisseur de soins de première ligne organise les examens et les consultations. Cette étude décrit les méthodes de détection, l’intervalle diagnostique et l’utilisation des UED pour le cancer du sein en Ontario.L’étude a porté sur une cohorte de 6 898 femmes ayant reçu un diagnostic de cancer du sein envahissant en 2011. Nous avons utilisé le Registre d’inscription des cas de cancer de l’Ontario jumelé à des bases de données administratives sur les soins de santé. Nous avons déterminé la méthode de détection à l’aide des données du Programme ontarien de dépistage du cancer du sein (PODCS) et des demandes de règlement des médecins. L’intervalle diagnostique a été défini comme le temps écoulé entre le dépistage initial, l’aiguillage vers un spécialiste ou la première épreuve diagnostique et le diagnostic de cancer lui-même. Le parcours diagnostique (qu'il passe par les UED ou les soins habituels) a été déterminé en fonction des dossiers du PODCS et du lieu de biopsie ou d’intervention chirurgicale. Nous avons cartographié l’intervalle diagnostique et de la couverture des UED en fonction du lieu de résidence des femmes.En 2011, 36 % des cas de cancer du sein en Ontario ont été détectés par dépistage, dont 48 % chez des femmes de 50 à 69 ans. L’intervalle diagnostique provincial médian était de 32 jours, les médianes par comté variant entre 15 et 65 jours. À l’échelle provinciale, 48,4 % des cas ont été diagnostiqués dans une UED, ce pourcentage variant entre 0 et 100 % selon les comtés.Le taux de détection au dépistage correspondant aux patientes admissibles du fait de leur âge s'est révélé inférieur au taux de dépistage officiel du cancer du sein pour l’ensemble de la population. La répartition géographique de l’intervalle diagnostique et du recours aux UED révèle des variations régionales dans les soins diagnostiques en oncologie qu'il est nécessaire de corriger.

Background: The duration of the cancer diagnostic process has considerable influence on patients' psychosocial well-being. Breast diagnostic assessment units (DAUs) in Ontario, Canada are designed to improve the quality and timeliness of care during a breast cancer diagnosis. We compared the diagnostic duration of patients diagnosed through a DAU vs usual care (UC). Methods: Retrospective population-based cohort study of 2499 screen-detected breast cancers (2011) using administrative health-care databases linked to the Ontario Cancer Registry. The diagnostic interval was measured from the initial screen to cancer diagnosis. Diagnostic assessment unit use was based on the biopsy and/or surgery hospital. We compared the length of the diagnostic interval between the DAU groups using multivariable quantile regression. Results: Diagnostic assessment units had a higher proportion of patients diagnosed within the 7-week target compared with UC (79.1% vs 70.2%, P

ObjectivesEarly diagnosis leads to better cancer survival and short diagnostic intervals reduce patient anxiety. We are studying factors that prolong the breast cancer diagnostic process in Ontario, Canada. ApproachThis is a retrospective study of all patients diagnosed 2007-2011 (n=33,752). We linked data from Cancer Care Ontario and the Institute for Clinical Evaluative Sciences including: Ontario Cancer Registry, physician claims, ambulatory, ER visits, and hospital discharges. Detection method (screening versus symptomatic) was determined using Screening Program and claims data. The diagnostic interval is the time from first relevant health care encounter to the definitive diagnosis. Elements of the diagnostic interval include: use of imaging, biopsy, and the number of encounters and providers. ResultsOverall, 30.6% were screen-diagnosed and the median diagnostic interval was 40 days (IQR 21-80). The median interval was shorter in the screened group at 32 days versus symptomatic at 45 days. The diagnostic interval was longer for stage I patients at 47 days compared to stage II (37 days), stage III (33 days) or stage IV (22 days). Stage IV patients were less likely to be diagnosed via biopsy (44% vs 61%) and the symptomatic stage IV subgroup less likely to have breast imaging (61% vs 96%). 26% of stage IV patients saw 0 or 1 providers while 8% of stage I patients saw 6 or more. 19% of stage I patients had 10 or more encounters overall versus 15% and 28% had >1 mammogram versus 14%. Effects are largely similar in screened and symptomatic groups. ConclusionShorter diagnostic intervals in stage IV are associated with a more direct diagnostic path. We will present results quantifying the number of days attributable to the diagnostic elements. Understanding the impact of elements of the diagnostic process provide targets for improvement of its length.

Patients with lung cancer have numerous and varying needs spanning across the cancer trajectory; however, only limited research has focused specifically on the pre-diagnosis phase. A multicentre cross-sectional survey was conducted to explore the experience of lung cancer patients during the pre-diagnosis phase. High levels of anxiety were reported by many participants (45.6 %). Informational (32.1 %), and emotional (24.1 %) needs were reported as most important; the majority (89.0 %) reported these needs were met. Most participants sought information throughout, with many (38.6 %) rating their oncology health care providers to be the best source of information. The majority (70.0 %) reported that they were not directed to any resources to help address their anxiety. During pre-diagnosis, informational and emotional needs appear most important, and for the majority, these were reportedly met. Although many experienced high levels of anxiety, few were directed to resources to address it.

The diagnostic phase of cancer care is an anxious time for patients. Patient navigation is a way of assisting and supporting individuals during this time. The aim of this review is to explore patient navigation and its role in the diagnostic phase of cancer care. We reviewed the literature for definitions and models of navigation, preparation for the role and impact on patient outcomes, specifically addressing the role of the nurse in patient navigation. Interviews and focus groups with healthcare providers and managers provided further insight from these stakeholder groups. Common to most definitions of navigation is the navigator's multifaceted role in facilitating processes of care, assisting patients to overcome barriers and providing information and support. Navigation may be provided by laypersons, clerical staff and/or healthcare professionals. In the diagnostic phase it has the potential to affect efficiency of diagnostic testing, patients' experience during this time and preparation for decision-making around treatment options. Patient care during the diagnostic phase requires various levels of navigation, according to individual informational, physical and psychosocial needs. Identifying those individuals who require more support--whether physical or psychosocial--during the diagnostic phase is of critical importance.

The length of the cancer diagnostic interval can affect a patient's survival and psychosocial well-being. Ontario Diagnostic Assessment Units (DAUs) were designed to expedite the diagnostic process through coordinated care. We examined the effect of DAUs on the diagnostic interval among female patients with symptomatic breast cancer in Ontario using the Ontario Cancer Registry linked to administrative healthcare data. The diagnostic interval was defined as the time from patients' first referral or test to the cancer diagnosis. DAU use was determined based on the hospital where the breast biopsy/surgery was performed. Multivariable quantile regression and logistic regression analyses adjusted for possible confounders. Forty-seven per cent of patients were diagnosed in a DAU and 53% in usual care (UC). DAUs achieved the Canadian timeliness targets more often than UC (71.7% vs. 58.1%, respectively). DAU use was associated with a 10-day (95% CI: 7.8-11.9) reduction in the median diagnostic interval. This effect increased to 19 days for patients at the 75th percentile and 22 days for those at the 90th percentile of the diagnostic interval distribution. Use of an Ontario DAU is associated with a shorter time to diagnosis in patients with symptomatic breast cancer, especially for those who would otherwise wait the longest.

1 Background: The provincial cancer agency in Ontario developed and implemented a model of care (MOC) for breast cancer (BC) survivors to transition from oncology-lead care to primary care in a publically funded health care environment (2010-2013). Transition options included direct to primary care and stepped transition. The objective of our study was to examine the health system resources used by the women in the MOC group and compare them to those used by women who did not transition. Methods: A propensity score matched, quasi-experimental approach was used to compare the healthcare resource utilization and costs between BC survivors in the MOC program (case) and those receiving usual care (control). All MOC cases were linked using unique identifiers and linked into the provincial health system databases. Cases and controls were matched 1:1 on year of diagnosis and location of care and were followed from an index date to the earliest of her death date, date of last contact in the database, one day before another cancer diagnosis or the end of study available databases. The primary study outcome was overall health system utilization and mean cost during the follow-up period. Results: There were 2324 women in the MOC program. Demographic information (age, region, stage) were well balanced between cases and controls. Transitioned cases had lower hospitalizations (20.1% vs. 24.4%, p

Nurse educators must confront the issue of nursing students' personal safety in community health practice, provide the necessary knowledge and skills, and document their actions. Learning opportunities are required to assist students to recognize and evaluate risks, and prevent their consequences. Thematic analysis of interviews with 56 public health nurses in Alberta, Canada uncovered knowledge, skill, and attitudinal components of risk assessment. Categories under the theme framing personal risk in work environments and the sub-themes framing for action and framing for no action provided a conceptual framework for planning educational strategies. Based on how these nurses framed their personal risk, 4 educational strategies are presented: a checklist, small group learning activities, a template for Web-based courseware, and a problem-based learning scenario.

115 Background: For many patients going through diagnostic testing for cancer, the time from suspicion to diagnosis or rule-out, can be a confusing and anxious time. In 2007, Cancer Care Ontario began investing in the implementation of diagnostic assessment programs (DAPs) across Ontario, Canada to improve the quality of care during the diagnostic phase of lung cancer. DAPs consist of multidisciplinary healthcare teams that manage and coordinate a patient’s diagnostic care from testing to a definitive diagnosis. The objectives of the DAPs are to: 1) decrease time from suspicion to diagnosis or resolution; 2) optimize the patient’s experience during the diagnostic process; 3) optimize satisfaction and experience among primary care providers and specialists; and 4) provide a sustainable solution by offering good value for money. Today over 35,000 patients have been diagnosed in one of the 18 lung DAPs that exist across the province. Methods: The implementation of DAPs featured the introduction of a patient navigator to act as the primary point of contact for patients, improve the patient experience and ensure their patients were progressing through any required diagnostic imaging and consultations in a timely manner. Cancer Care Ontario also engaged with primary care providers to refer patients with findings suspicious for lung cancer to DAPs as early as possible to ensure they benefited from organized assessment. Cancer Care Ontario has collected patient level data to measure wait times and implemented a patient survey to assess patient experience. Results: In the past five years, the median wait time from referral to a lung DAP to diagnosis or rule out has decreased by 19% to 24 days and the 90th %tile has decreased by 28% to 51 days. The large majority of patients have had a positive experience with their DAPs, with 95% of patients scoring their experience in the diagnostic process as “good” or “excellent”. Conclusions: The implementation of DAPs across the province is seen as a valuable component of quality of care by improving the diagnostic phase of cancer. The sustainability of the DAP model is demonstrated by the continued improvements in access and maintained patient experience in spite of growing volumes (91% increase in the past five years).

Patients with colorectal cancer (CRC) face a number of challenges leading up to diagnosis; however, research is limited regarding their specific needs during the pre-diagnosis period. A multicenter cross-sectional survey was conducted to elicit information about the CRC experience during the pre-diagnosis phase. Across the three sites, 104 eligible patients were approached, and 82 patients completed the survey, for a total response rate of 78.9 %. The needs most identified by participants during the pre-diagnosis period were informational (31.6 %) and emotional (20.3 %) needs; social needs were rated as the least important need for these patients (7 %). The majority (84.0 %) reported that these needs were met. Participants reported feeling shocked or overwhelmed on learning of their diagnosis (57.1 %) and high levels of anxiety during this time (40.0 %). The majority (77.9 %) of participants reported that they were not directed to any resources to help address their anxiety. Informational and emotional needs are identified as the most important needs during the pre-diagnosis phase, and for most these needs are being met; however, some participants are experiencing high levels of anxiety without access to appropriate resources. Further work is required to understand the optimal mechanisms to address identified needs during this pre-diagnosis period and to assess the potential benefits and costs of addressing these needs.

A literature review was conducted on recent studies using family therapy approaches to the treatment of conduct disorders in adolescents. Results from studies conducted since the Shadish et al. (1993) meta-analysis on the effects of family and marital therapies are included. Barriers to effective treatment are identified, costs of care are discussed, and a variety of systems of care in which family interventions are embedded are reviewed.

118 Background: The True NTH Initiative aims to improve the lives and experiences of men with prostate cancer, as well as those of their partners, family and caregivers. In Canada, Prostate Cancer Canada selected ten teams to develop, implement and evaluate evidence-informed programs focusing on decision support, clinical support, lifestyle management, education, social support, navigation and treatment follow-up. Project teams were encouraged to align their local evaluations with a common evaluation framework and a national evaluation plan was developed. The aim of this abstract is to share methodology and early results of a multi-level evaluation that will address a range of programs designed to improve the lives of men with prostate cancer. True NTH is funded globally by the Movember Foundation, and operates in Canada, USA, UK, Australia, New Zealand, Ireland and Singapore. Methods: Projects (Solutions) selected for the initiative had existing evidence for their efficacy. Project teams were responsible for designing the implementation of their Solution and an appropriate evaluation. Local and national evaluations used a recognized framework (RE-AIM) to systematically study the real world uptake of these interventions, focusing on questions of Reach, Effectiveness, Adoption, Implementation, and Maintenance. Project teams provide quarterly narrative updates and annual written reports with quantitative measures and narrative components. Key informant interviews with project leads will complete the final national evaluation. Results: To date, projects have generated learning across different provincial health systems, academic institutions and community settings. Teams have learned to address challenges of participant recruitment and project endorsement, and have begun to appreciate the benefits of collaboration. Teams have also reflected on the importance of engaging clinicians in the implementation of their Solutions for effective uptake and sustainability. Conclusions: The results of the ongoing multi-level evaluation continue to provide insight into real world implementation of evidence-informed programs and the critical factors that enable their effectiveness.

Context The Provincial Palliative Care Integration Project (PPCIP) was implemented in Ontario, Canada, to enhance the quality of palliative care delivery. The PPCIP promoted collaboration and integration across service sectors to improve screening and assessment, palliative care processes, as well as clinician practice and outcomes for cancer patients. Objectives The project involved 1) implementation of the Edmonton Symptom Assessment System (ESAS) for symptom screening, 2) use of "rapid-cycle change" quality improvement processes to improve screening and symptom management, and 3) improvements in integration and access to palliative care services. Methods Symptom scores were collected and made accessible to the care team through a web-based tool and kiosk technology, which helped patients enter their ESAS scores at each visit to the regional cancer center or at home with their nurse. Symptom response data were gathered through clinical chart audits. Results Within one year of implementation, regional cancer centers saw improvements in symptom screening (54% of lung cancer patients), symptom control (69% of patients with pain scores and 31% of patients with dyspnea scores seven or more were reduced to six or less within 72 hours), and functional assessment (23% of all patients and 64% of palliative care clinic patients). ESAS screening rates reached 29%, and functional assessment reached 26% of targeted home care patients. Conclusion The PPCIP demonstrated that significant strides in symptom screening and response can be achieved within a year using rapid-cycle change and collaborative approaches. It showed that both short- and long-term improvement require ongoing facilitation to embed the changes in system design and change the culture of clinical practice.

The purpose of this qualitative study was to conduct a thematic analysis of unanalyzed semistructured interview segments from data that emerged during an earlier exploratory descriptive study on organizational factors and work hazards. The sample consisted of 56 transcribed interviews with staff and managerial public health nurses (PHNs) in five health units of the Province of Alberta before health care restructuring. The framework that resulted from this secondary analysis describes the ideologies (values, beliefs, concepts, and attitudes) of female PHNs related to their workplace environmental risks. Four categories of the overarching theme, framing personal risk in work environments, emerged: becoming aware, recognizing influences, comparing with others, and knowing rights and freedoms. Two subthemes also emerged: framing for no action and framing for action. When framing for no action, PHNs were either unconcerned or wanted to avoid trouble. When framing for action, PHNs found humor, took responsibility, used voice, collected support, and struggled for action.

9621 Background: The morbidity of patients with cancer would be significantly reduced if they received optimal symptom management. This requires early identification of the symptoms, comprehensive ...