Integrated care pathway for rectal cancer treatment: cross-sectional post-implementation study using a logic model framework

Kobayashi, Silvia Takanohashi; Campolina, Alessandro Gonçalves; Diz, Maria del Pilar Estevez; Soárez, Patrícia Coelho de

doi:10.1590/1516-3180.2018.0364160919

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Sao Paulo Medical Journal

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ORIGINAL ARTICLE • Sao Paulo Med. J. 137 (05) • Sep-Oct 2019 • https://doi.org/10.1590/1516-3180.2018.0364160919 copy

Integrated care pathway for rectal cancer treatment: cross-sectional post-implementation study using a logic model framework

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND:

Management of rectal cancer has become more complex with multimodality therapy (neoadjuvant chemoradiotherapy and surgery) and this has led to the need to organize multidisciplinary teams. The aim of this study was to report on the planning, implementation and evaluation of an integrated care pathway for neoadjuvant treatment of middle and lower rectal cancer.

DESIGN AND SETTING:

This was a cross-sectional post-implementation study that was carried out at a public university cancer center.

METHODS:

The Framework for Program Evaluation in Public Health of the Centers for Disease Control and Prevention (CDC) was used to identify resources and activities; link results from activities and outcomes with expected goals; and originate indicators and outcome measurements.

RESULTS:

The logic model identified four activities: stakeholders’ engagement, clinical pathway development, information technology improvements and training programs; and three categories of outcomes: access to care, effectiveness and organizational outcomes. The measurements involved 218 patients, among whom 66.3% had their first consultation within 15 days after admission; 75.2% underwent surgery < 14 weeks after the end of neoadjuvant treatment and 72.7% completed the treatment in < 189 days. There was 100% adherence to the protocol for the regimen of 5-fluorouracil and leucovorin.

CONCLUSIONS:

The logic model was useful for evaluating the implementation of the integrated care pathways and for identifying measurements to be made in future outcome studies.

KEY WORDS (MESH TERMS):
Rectal neoplasms; Interdisciplinary studies; Disease management; Implementation science; Decision making; Qualitative research

AUTHOR KEY WORDS:
Line of care; Chronic non-communicable diseases; Healthcare work

Concept and evaluation criteria	Measurements/indicators	Goal	Description	Source
Outputs
1. Pathway implantation	Time interval between electronic medical record flagging and first consultation (days)	≤ 15 days	mean, % patients within the target	electronic health records
	Time interval between first medical consultation and start of neoadjuvant treatment (days)	≤ 46 days	mean, % patients within the target	electronic health records, radiation therapy system
	Time interval between start and end of neoadjuvant treatment (days)	≤ 45 days	mean, % patients within the target	radiation therapy system
	Time interval between end of neoadjuvant treatment and surgery (weeks)	≤ 14 weeks	mean, % patients within the target	electronic health records
	Time interval between first medical consultation and surgery (days)	≤ 189 days	mean, % patients within the target	electronic health records
	Adherence to FULV regimen protocol for concomitant chemotherapy	100%	% adherence	electronic health records
Early outcomes
1. Access to care	Time interval between admission and first consultation (days)	Comparison of the measurements of pathway implementation with the period before ICP implementation	mean, % patients within the target	electronic health records
	Time interval between first medical consultation and start of neoadjuvant treatment (days)	Comparison of the measurements of pathway implementation with the period before ICP implementation	mean, % patients within the target	electronic health records
	Time interval between end of neoadjuvant treatment and surgery (weeks)	Comparison of the measurements of pathway implementation with the period before ICP implementation	mean, % patients within the target	electronic health records
2. Effectiveness of care	Time interval between first medical consultation and surgery (days)	Comparison of the measurements of pathway implementation with the period before ICP implementation	mean, % patients within the target	electronic health records
3. Organizational outcomes	Resource use	Comparison of the measurements of pathway implementation with the period before ICP implementation	numbers of consultations, CT scans, MRI scans, colonoscopies and radiotherapy sessions	administrative database
Later outcomes
1. Effectiveness of care	Overall survival time	Comparison of the measurements of pathway implementation with the period before ICP implementation	survival curves	retrospective cohort study
2. Organizational outcomes	Cost evaluation	Comparison of the measurements of pathway implementation with the period before ICP implementation	cost of treatment	retrospective cost analysis

Measures/indicators	Indicator goal	% ICP within goal	ICP (n = 218)
∆ EMR flagging - first consultation (days)
mean (SD)	≤ 15 days	66.3	12.7 (8.8)
95% CI			(11.5-14.1)
median			13.0
∆ first consultation - start of nCRT (days)
mean (SD)	≤ 46 days	67.9	48.4 (29.8)
95% CI			(44.3-52.3)
median			39.0
∆ first - last nCRT session (days)
mean (SD)	≤ 45 days	89.9	40.1 (6.7)
95% CI			(39.2-41.0)
median			39.0
∆ last nCRT session - surgery (weeks)
mean (SD)	≤ 14 weeks	75.2	14.8 (4.6)
95% CI			(14.2-15.4)
median			13.2
∆ first consultation - surgery (days)
mean (SD)	≤ 189 days	72.7	192.0 (45.8)
95% CI			(185.9-198.1)
median			177.0
Adherence to FULV1 regimen protocol	100%	NA	100%

Associação Paulista de Medicina - APM APM / Publicações Científicas, Av. Brigadeiro Luís Antonio, 278 - 7º and., 01318-901 São Paulo SP - Brazil, Tel.: +55 11 3188-4310 / 3188-4311, Fax: +55 11 3188-4255 - São Paulo - SP - Brazil
E-mail: revistas@apm.org.br

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[1] Address for correspondence: Silvia Takanohashi Kobayashi. Instituto do Câncer do Estado de São Paulo. Av. Dr Arnaldo 251, Cerqueira Cesar - São Paulo (SP) - Brasil. CEP 01246-000. Tel. (+55 11) 3893-3550. E-mail: silvia.kobayashi@uol.com.br

Background	Period prior to implementation of the integrated care pathway: A public teaching hospital specializing in oncology opened its doors in May 2008, to treat public healthcare system patients who had been diagnosed with cancer. Patients were admitted by medical oncologists or surgeons. Although the established multimodal treatment for middle or lower rectal cancer consisted of neoadjuvant chemoradiotherapy followed by surgical resection, there was no coordination between the phases, which harmed the continuity of care. Until 2010, radiotherapy was done in a different service.
Goal	To implement an integrated care pathway for neoadjuvant treatment of rectal cancer, consisting of radiotherapy with 5040 cGy delivered in 28 fractions (540 cGy in the boost phase and 4500 cGy in the pelvic phase), over a five-week period. Concomitant chemotherapy (FULV regimen¹² with 350 mg/m² of 5-fluorouracil and 20 mg/m² of leucovorin) was delivered as two five-day courses during the first and fifth weeks of radiotherapy. Surgery with total mesorectal excision consisted of open rectosigmoid resection (ORR), laparoscopic rectosigmoid resection (LRR) or abdominoperineal resection (APR).
Objectives	To manage all steps of the treatment for middle and lower rectal cancer and provide multidisciplinary continuity of care.
Inputs
1. Service users	Inclusion Criteria: Patients with rectal cancer Exclusion Criteria: Patients with metastatic disease at diagnosis Patients who were unable to undergo neoadjuvant treatment: clinical condition precluded the use of nCRT; or immediate surgery was indicated; or a rapid course of neoadjuvant radiotherapy was indicated Patients who had previously been treated for cancer Patients who had not adhered to the nCRT regimen
2. Resources	Human Resources: medical oncologists, gastrointestinal surgeons, radiation oncologists, endoscopists, radiologists, pathologists, anesthesiologists, physicians, nurses, dieticians, social workers, psychologists, physiotherapists, hospital administrators and data managers
	Facilities: chemotherapy sector, radiotherapy sector, operating rooms, inpatient units, consultation rooms, imaging service and electronic medical records
Activities
1. Stakeholder engagement	Clinical staff engagement: Multidisciplinary meetings were held under the leadership of a board of directors. Medical oncologists, surgeons, radiation oncologists, radiologists, pathologists, clinicians and anesthesiologists reviewed the neoadjuvant treatment protocol for middle and lower rectal cancer and defined the intervals between the phases of the treatment.
2. Clinical pathway development	An integrated care pathway was designed as a flowchart by the administrative group. Identification of patients’ input into the clinical pathway Definition of the time interval between record screening and the first medical consultation Booking first medical consultations on the pathway Staging test standardization Definition of term reports Sharing of chemotherapy and radiotherapy session schedules Active monitoring of surgery requests Definition of time interval between neoadjuvant treatment and surgery
3. Information technology improvements	Enablement of pathway patient identification using a flag added to the electronic patient charts Development of a report to identify pathway patients who have consultations and tests scheduled Development of a report to identify pathway patients who do not have any scheduling Development of a report to calculate dates of future steps on the pathway, to help in reception sector scheduling Development of the flag deactivation process
4. Training program	Training program for outpatient reception workers to enable schedule tests and consultations in accordance with the flowchart Training program to enable use of the reports that have been developed Training program to activate flags: regulation sector Training program to deactivate flags: physicians