Poor implementation of survivorship care plans (SCPs) ultimately limits the ability to determine whether they work, according to Sarah A. Birken, PhD, Assistant Professor in the Department of Health Policy and Management at the University of North Carolina at Chapel Hill.According to Dr Birken, the effectiveness of SCPs is determined, in part, by context and delivery. "We have a lot of evidence that the implementation of SCPs is not optimal, and if there is inconsistent implementation in randomized controlled trials, you can imagine what it looks like in practice," she said at the ASCO Cancer Survivorship Symposium. "We really need to understand the implementation of SCPs before we can understand whether they're effective." Implementation refers to the proficiency and consistency with which any intervention, including the SCP, is used. Proficiency is the extent to which something is used as intended, whereas consistency refers to the extent to which the targeted population receives the intervention. According to Dr Birken, both are lacking when it comes to the delivery of SCPs.
In their research, Dr Birken and colleagues found that the "usual suspects" were determinants of poor SCP implementation: lack of time, money, and staff. "But we wanted to dig a little bit deeper to understand what was driving the use of SCPs," she said.In addition to the usual suspects, the team found that cancer care providers' beliefs about the consequences of SCPs influenced their use, that is, "Is what I'm doing making a difference for anyone?" Having a leader who identified the use of SCPs as an organizational priority was also found to be a determinant. The researchers worked alongside the Quality Oncology Practice Initiative (QOPI), an organization comprised of over 600 participating practices. QOPI practices collect and submit data regarding several quality benchmarks, of which SCP implementation is one. To identify strategies for the successful implementation of SCPs, Dr Birken and her team conducted interviews in 21 QOPI cancer programs with varying degrees of SCP implementation success. "We found that high-performing cancer programs saw the requirements coming, and they started implementing early," she said. "They phased in their efforts to implement SCPs slowly and carefully and looked at requirements as an opportunity to improve their approach to survivorship care instead of simply checking a box to comply." According to Dr Birken, high-performing cancer programs had someone in a leadership position who recognized the importance of the significant efforts involved in SCP implementation and stood behind them. They also appropriately delegated responsibility for SCP implementation and shielded the people in the organization who were not tasked with implementation, so that they could focus on their clinical and administrative duties.
"Very importantly, successful cancer programs ensured that this effort was not comprised of 1 highly motivated employee who, if they became sick or went on vacation, would result in the entire survivorship program falling apart," she added. They also found that auto-population of SCPs through electronic health records enhanced the influence of these tactics.However, she warned that integrating these strategies into the appropriate workflow is critical for successful implementation. "Careful integration of these concepts is required in a way that makes sense for the particular context," she added. "Because taken out of context, these strategies might not work." Overall, successful SCP implementation requires minimizing the burden on organizations and their employees and maximizing the benefit to survivors, caregivers, and primary care providers.