Medication Counseling and Adherence to Oral Chemotherapy

The Elston Lafata Team is committed to improving oral medication adherence and management in cancer care. Oral antineoplastic therapy, also known as oral chemotherapy, is unique in its frequent use of repeated treatment-rest cycles, concerns regarding toxicity, evidence of overuse, and need for ongoing symptom monitoring at home. With the use of oral antineoplastic therapy expanding, it is important to understand how best to support patients’ adherence to these oral agents. To date, we have launched a total of 3 projects to explore this complex issue.

Patient-Oncologist Communication regarding Oral Chemotherapy during Routine Office Visits

We recently completed a qualitative study to understand how oncologists discuss oral capecitabine with their patients with colorectal cancer. We were particularly interested in the medication counseling patients received and how the patient’s adherence to the prescribed regimen was discussed. Using medical office visit audio recordings/transcripts collected for the Verilogue™ database, we coded and analyzed transcript data and classified the content of patient-provider conversations about oral anticancer medications. A manuscript presenting findings from this study was published in the Journal of Oncology Practice in early 2020.

Patient-provider Communication and Oral Chemotherapy Adherence

We conducted a systematic review to identify key patient-provider communication strategies that support patients’ adherence to oral chemotherapy. Results from this review, identified multiple communication gaps in current practice as well as intervention opportunities to improve cancer care quality.

Patient-Targeted Colorectal Cancer Screening Decision Support

Colorectal cancer is the second leading cause of cancer death in the United States. While several effective screening methods exist, screening remains underutilized. Prior research has shown that more than 90% of primary care patients receive a physician recommendation for screening when they are due, but just over half of those who receive such recommendations go on to be screened in the next year. Since 2015, our team has worked in partnership with health care delivery organizations to close the gap between physician recommendation for screening and screening uptake among primary care populations. Our overarching goal is to develop effective practice-integrated decision support programs that are accessible and acceptable to broad segments of the population.

Leveraging the EHR and Patient Portal Infrastructure

With funding from the National Cancer Institute (R01 CA197205 Elston Lafata), we worked in partnership with Henry Ford Health to develop and test a patient-targeted, colorectal cancer screening decision-support program. The program, called e-assist: Colon Health is designed to facilitate the uptake of physician-recommended colorectal cancer screening by educating patients about their screening options and addressing individual barriers to screening. Findings have been published in:

Text Messaging to Enhance Decision Support among Diverse Populations 2019-2021

With developmental funding from the UNC Lineberger Comprehensive Cancer Center, we are working to examine the feasibility of text messaging to reach socio-demographically diverse patients at the time of a colorectal cancer screening decision and support them in making a decision to screen. Our text-messaging project consists of three phases. In the first phase, we employed an online cohort to evaluate candidate text messages for their relevance, salience, usability, and impact on participant’s intentions to use text-based decision support; these results can be found in the Journal of Medicine and Internet Research. In Phase II, we will pilot the program in partnership with the UNC Health Care System.

Cancer Care Quality Improvement

The overarching goal of the UNC Cancer Care Quality Initiative (CCQI) is to support the North Carolina Cancer Hospital’s ability to deliver value-based oncology care. In partnership with UNC Health Care practitioners, we are developing an informatics infrastructure to support oncology population management. We use data analytics to monitor the care quality delivered to UNC Health Care patients and to identify opportunities for improvement. CCQI strives to ensure the development of reliable and valid clinical performance metrics and other analytical capabilities to support care standards and the informatics infrastructure needed by practitioner teams to take appropriate actions and achieve measurable, desired outcomes. We strive to allow real time identification of patients throughout the cancer care continuum enabling:

• Identification of gaps in evidence-based care
• Patient risk stratification for targeted service delivery
• Decision support for patients and clinicians
• Continual performance monitoring and tracking of outcomes

Our current activities include:

• Developing a system-wide Cancer Care Quality Dashboard that will be used as platform for real time communication of quality data
• Developing the infrastructure to identify and attribute patients receiving cancer treatment at one UNC Health Care’s six locations across the state
• Collaborating with clinical and other cancer care leaders to ensure our reporting meets the needs of clinical teams and adequately supports care quality efforts
• Collaborating with QI teams to address disparities in unplanned visits to the emergency department and hospital (called acute care events) among patients receiving treatment for cancer.

Other Current Research

Implicit bias, communication behaviors and care outcomes among black patients with type 2 diabetes

Although we know that medication non-adherence is prevalent among African Americans with diabetes, and that patient-clinician communication contributes to patients’ medication adherence, we know little about how physician implicit bias may present during office visits. In this grant, we are collaborating with researchers at Virginia Commonwealth University and the University of Michigan (R01 DK112009 Hagiwara) to identify clinician communication behaviors associated with implicit bias and, in turn, studying the association between these communication behaviors and the outcomes of black patients with Type 2 diabetes, including patients’ medication adherence and diabetes self-management behaviors.

Understanding the lung cancer screening process

Numerous organizations, including the United States Preventive Services Task Force, recommend annual lung cancer screening with low-dose computed tomography (LDCT) for high-risk adults who meet specific criteria. Despite these recommendations, lung cancer screening remains underused in the United States. We are currently participating in two NCI-funded studies pertaining to lung cancer screening. Both of these projects while relying heavily on data from the electronic health record to understand opportunities to improve the quality of lung cancer screening delivered to diverse patients, also have a focus on the decision making process currently being used by patients and clinicians.

In the first (UMI-CA221939 Pearson-Ritzwoller and Vachani), we are collaborating with researchers in NCI’s Population-based Research to Optimize the Screening Process (PROSPR) consortium. As a member of the Lung PROSPR Research Consortium, we are working with five diverse healthcare systems in Colorado, Hawaii, Michigan, Pennsylvania, and Wisconsin to examine lung cancer screening use and outcomes across diverse populations. As part of this effort, we are assessing how variations in the implementation of LCS programs, including how shared decision making has been implemented, effect outcomes across the screening process.

In the second (R01 CA2220990 Carter-Harris), we are using a mixed methods study to understand the “active ingredients” in lung cancer shared decision making and examine the predictors of positive decisional and behavioral outcomes to enable the development of lung cancer screening decision support interventions. This grant is in collaboration with researchers at Memorial Sloan Kettering and Kaiser Permanente Washington.