Is it worth reorganizing cancer services on the basis of network-based models to produce integration at the point-of-care? Lessons learned from Quebec

摘要

Context : Optimal management in the diagnosis, treatment and support of cancer patients is increasingly associated with network-based models of care, an approach promoted by experts worldwide and pursued as a key objective in many national cancer plans. The Quebec national cancer plan proposed that fragmentation of care should be remedied through creating local cancer networks (LCNs). Objective: To measure to what extent a mandated cancer network, prescribed at the policy level but operationalized at the point-of-care, produce integration. Methods : This research is part of a larger study aiming at analyzing the implementation of a mandated cancer network in Quebec1. Data were collected through a survey of stakeholders from four local cancer networks (LCNs) using the Health System Integration Study questionnaire. The instrument consists of 64 questions ordered to reflect the degree of implementation of integration (functional, normative, clinical and professional). Data were analyzed using descriptive statistics of score aggregation by network (mean, standard deviation (SD), intraclass correlation coefficient (ICC)) Results : Globally, participants-reported (n=83) scores of integration (min=0; max=100) range from 48 (SD=31) to 84 (SD=28). The proportion of participants reporting a positive perception of the integration dimensions varied by network: functional (59 to 78 %), normative (68 to 88 %), clinical (46 to 64 %) and professional (47 to 77 %) ICC by network range from 0.24 to 0. 57. Discussion : Although data only represent preliminary analysis, empirical results suggest that “prescribed” networks at the policy level lead to a partial and widely varied integration. LCNs have simultaneously invested efforts in integration to conform to the Quebec cancer plan. Functional and normative integration appeared more advanced and more internally agreed than clinical and professional dimensions. Results raise questions about agreement from LCNs partners. Conclusions : Additional work is needed to examine how national cancer programs promoting network-based practices reach the point-of-care and ultimately cancer patients. Further analysis of our study data will provide more detailed results of which contextual and individual characteristics facilitate or impede each dimension of integration. Lessons learned : The key lesson learned is that implementation of network-based practices are major experiment operating in a challenging professional bureaucracy. Cancer care providers respond differently to network-based form mandated at the policy level. Policymakers should anticipate variation in local context, and various strategies to dive into the micro dynamics of coordinated care. Limitations : This presentation build upon preliminary analysis, and further work is required to offer more detailed results. Considering the characteristics of our sample and because access to cancer services is universal in Quebec, we feel cautious about generalizing our results to other healthcare systems. Nevertheless, our study contributes to the numerous efforts to demonstrate intermediate outcomes of mandated cancer networks. Future Research : Further analysis will examine in detail the sub-scales of each integration dimensions. Analysis will be performed to determine the association between the activation of governance functions (distal macro level) and the integration in LCNs (local micro level).