Veterans are vulnerable to delays in cancer treatment, and treatment initiation is significantly longer for patients with hepatocellular carcinoma (HCC), a complex cancer diagnosis. Appropriate HCC treatment evaluation requires multidisciplinary input from a team of specialists that is best provided through the tumor board (TB) platform, a multidisciplinary forum designed to provide quality cancer care. However, Veterans with HCC often receive treatment recommendations without multidisciplinary input. Although TB are common in the VA setting, there is no universal standardized tool within the VA to ensure appropriate multidisciplinary evaluation of cancer cases during the TB encounter. There is no standardized process for implementing TB recommendations or conveying information to patients. Substandard TB processes, including lack of appropriate multidisciplinary evaluation for complex cancers, can result in significant delays in treatment initiation. Therefore, it is hypothesized that standardized TB processes, including multidisciplinary evaluation and identification of actionable next steps for patients and providers will facilitate timely initiation of treatment for Veterans with HCC.
This study proposes to develop a multi-level intervention to improve HCC care in three ways: 1) Implement standardized TB processes to promote appropriate multidisciplinary evaluation 2) Expedite specialist referrals to facilitate timely initiation of treatment and 3) Increase patient engagement in the treatment plan. Therefore, the specific aims of this project are: 1) To conduct a comprehensive review of VA electronic medical records to identify TB process factors associated with appropriate multidisciplinary evaluation and examine the impact of TB involvement on timely referral and treatment initiation in a national sample of Veterans with HCC; 2) To use focus groups of patients and providers at three VA medical centers (Houston, West Haven and Philadelphia) to identify barriers and facilitators to timely referral and treatment initiation following TB evaluation for Veterans with HCC, and to explore the informational needs of Veterans regarding treatment recommendations; and 3) To develop and pilot test a TB-based multi-level intervention to improve multidisciplinary evaluation, expedite specialist referrals for treatment, and increase patient engagement with the treatment plan. We expect a reproducible intervention involving providers and patients that can be applied to Veterans with HCC nationally and serve as a model for care of other complex cancers within the VA system.
For Aim 1, the Houston team will conduct a comprehensive retrospective review of the VA's electronic medical records of a random sample of veterans diagnosed with HCC. For aim 2 we plan to use focus groups of providers and semi-structured interviews with patients at three VA medical centers: Houston, West Haven and Philadelphia. For aim 3 we plan to develop and pilot test a TB-based multi-level intervention at the Houston. The primary intervention will be a HCC-specific TB checklist, embedded within the VA electronic medical record system, and a patient engagement component. This checklist is built upon a previously validated tool for TB processes. The patient component of the intervention will include a clinical nurse patient navigator and utilize My HealtheVet to increase patient engagement in the treatment plan and improve patient satisfaction. Data obtained from Specific Aims 1 and 2 will directly inform the development of the intervention in Specific Aim 3. Findings from Specific Aim 3 will lay the groundwork for a subsequent grant submission proposing a large, randomized controlled trial of the proposed intervention in the VA system.
As part of Aim 1, the team has completed the chart abstraction component. We have reviewed the EMR of 904 veterans with the diagnosis of HCC and had that been seen by TB. General preliminary data from this review indicate: the average number of TB meetings per patient is 2.4 and the average number of days from diagnosis to first TB meeting is 68. The distribution of BCLC stage at the time of first TB is 0/A: 41.0%, B: 22.5%, B: 23.5%, C: 25.2%, D: 10.1%.
For Aim 2, we have completed patient and provider interviews at all 3 sites. We conducted a focus group of 6 physicians and semi-structured interviews with 10 patients at the Houston VAMC. From the Philadelphia VA, we conducted 10 patient interviews and interviews with 5 providers. From West Haven, we conducted a focus group of 10 providers and interviews with 10 patients. Important points for patients included the need to have available treatment options and discussion about their imaging. Suggestions for improving tumor boards included a standardization of images ordered, the inclusion of a summative/narrative statement in the TB note, and a copy of most recent imaging and lab results.
The proposed patient-centered intervention will impact patients directly by improving individualized care through a standardized tumor board multidisciplinary evaluation process and increase patient engagement in the treatment plan. The intervention will be designed to facilitate activation of care, convey transparent tumor board recommendations to patients, and improve patient satisfaction.
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