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PARTLY DIGITAL - ONLY FOR INVITEES (1,5 m) : PhD Defence Jolanda van Hoeve | Added value of oncological care parthways - Data supported with healthcare professionals' and patients' perspective

Added value of oncological care parthways - Data supported with healthcare professionals' and patients' perspective

Due to the COVID-19 crisis measures the PhD defence of Jolanda van Hoeve will take place (partly) online in the presence of an invited audience.

The PhD defence can be followed by a live stream.

Jolanda van Hoeve is a PhD student in the research group Health Technology & Services Research (HTSR). Her supervisor is prof.dr. S. Siesling from the Faculty of Behavioural, Management and Social Sciences (BMS).

Cancer is the second leading cause of death globally, accounting for an estimated 9.6 million deaths, or one in six deaths, in 2018. The main reasons for the increased incidence of cancer are aging, growth of the population, and changes in the prevalence and distribution of the main risk factors for cancer. Because cancer care is multidisciplinary and complex, it requires close collaboration among care professionals, based on the latest evidence, pooling their expertise and exchanging information.

Care pathways are used worldwide as methods for patient-care management of a well-defined group of patients during a well-defined period of time. They are based on guidelines, best practices and patient expectations by facilitating the communication, and coordinating roles. Care pathway enable sequencing the activities of the multidisciplinary care team, patients and their relatives, by documenting, monitoring and evaluating variances, and by providing the necessary resources and outcomes. Furthermore, care pathways may serve as useful and evidence-based tools to improve quality and outcomes of health care interventions, reduce variation in clinical practice, promote teamwork on a multidisciplinary team, facilitate the use of guidelines, and they may act as a basis for a payment system.

Care pathways were first developed in the 1980s in the United States and the United Kingdom. During the 1990s nursing pathways were developed, in which all aspects of patients care were incorporated, including medical and psychosocial care. Care pathways are widely used in cancer care.

Based on all developments of pathways in health care the main aims of pathways are: improve the multidisciplinary quality of care, reduce risks, increase patient satisfaction, and increase the efficiency in the use of resources.

The aim of this thesis was to determine whether the above mentioned goals for oncological care pathways were achieved. The effects of cancer care pathways were described, focusing on the quality of care, the added value for health care professionals and patients, and the applicability within oncology networks.



In the first part of this thesis the available literature about care pathways in cancer care was synthesized.

Chapter 2 describes a protocol which was written prior to the systematic review of effects on cancer care pathways. The main goal of this systematic review was to identify, assess, and synthesize high-quality evidence on the effects of cancer care pathways, meeting the Cochrane Effective Practice and Organisation of Care (EPOC) design criteria. The results of the systematic review were presented in Chapter 3. Out of more than 13,000 search results, eight studies were included in the review. Most of these studies were performed in secondary or tertiary care. Length of Stay (LOS) was the most common used indicator, and was reported in five studies. Subgroup meta-analysis showed an overall shorter LOS for patients with gastric cancer and gynecological cancer. Two studies reported measured effects in terms of complications and one study reported effects regarding readmissions. Costs were reported in six studies, and most studies reported significant lower costs in favor of cancer care pathways. Despite the low number of included studies and the differences between these studies, the systematic review provides an evidence base for the subgroup effects of LOS. The effects on complications, readmissions, and costs as well as implications of differences in implementation of cancer care pathways were not conclusive enough. This indicates the need for further well-designed research to provide insight in the effects of cancer care pathways.

As the systematic review focuses on the cancer care pathway, Chapter 4 examines the availability of evidence regarding transitions in cancer care pathways. This mixed methods review was based on a search conducted in the previous systematic review and aimed to provide a more complete picture of care pathways on transitions of care between primary, secondary and tertiary cancer care. Data analysis was performed using induction (data-driven generalization) and deduction (theory-driven exploration of hypothesis), and three descriptive themes were identified which guided the framework analysis: transition outcomes, coordination between settings and translation of guidelines. In this mixed methods review a total of 16 studies were included. Most studies covered the diagnostic phase, and some studies described transitions in treatment and follow-up. The included studies showed that shorter time intervals were associated with implemented guidelines in care pathways and enhanced coordination of care between settings or professionals.

To get more insight in the organization and personalization of care for patients with breast cancer,  Chapter 5 presents the results of an inventory of aftercare for breast cancer patients. The aim of the study was to gain insight in the similarities and differences in the organization of follow-up and identify best practices and opportunities for the future. After performing semi-structured in-depth interviews with health care professionals in seven Dutch hospitals, variation was found in the organization of aftercare (identifying and managing side and late effects of cancer), especially in timing an frequency and in disciplines of involved health care professionals. Less variation was found for follow-up (aimed at detection of recurrences), which is based on the national guideline. Opportunities for the future focus on improving monitoring of patients’ needs, developing a comprehensive guideline for the organization and content of aftercare, and further integration and personalization of follow-up.



The second part of this thesis investigates the added value of (regional) care pathways for patients with a low-complex high-volume tumor types (breast cancer) as well as a high-complex low-volume tumor types (esophageal and gastric cancer).

Chapter 6 shows the results of an evaluation of a regional care pathway for breast cancer patients in three hospitals. In this study quantitative data was supplemented with qualitative data based on interviews with health care professionals. Fourteen indicators were used to assess the quality of care before and after implementation of the pathway. In order to estimate the impact of the care pathway, related to evidence-based guidelines and profession-based norms, the involved project leaders of the hospitals were interviewed. The main results showed that more patients received a HER2neu test after implementation of the breast cancer pathway. Furthermore, more patients started the first chemotherapy or first radiotherapy within four weeks after surgery. Based on the interviews, the joint multidisciplinary meeting was seen as the key in the breast cancer pathway and was implemented in response to the development and implementation of the care pathway.

In Chapter 7 the effects of a regional care pathway for patients with rectal cancer were described. This study applied a mixed methods research design and focusses on the long term results after implementation of this rectal cancer care pathway within the four participating hospitals. Data on almost 400 patients were collected from two national databases. Results of seven structure and process indicators were analyzed and compared before and at two time points, over a total period from 2007 and 2012, after implementing a regional care pathway for patients with rectal cancer. Interviews were performed with relevant health care professionals of the participating hospitals to determine the motivation for developing and implementing the care pathway and to interpret the results. The results after implementing the care pathway were: an improved performance of computed tomography (CT) scans in the diagnostic phase, a higher number of patients discussed in the preoperative multidisciplinary meeting, and a reduction in lead time between the first tumor biopsy and the multidisciplinary meeting. Interviews with health care professionals indicated that the regional care pathway led to more clarity about the patient route and more awareness of complying with evidence-based guidelines. In conclusion, the regional care pathway provided a solid base to uniform care, working according evidence-based guidelines and further cooperation within the region. Nevertheless, the waiting and throughput times were affected by the guidelines and norms rather than the care pathway.

In Chapter 8 an evaluation of a regional collaboration for esophagogastric cancer in seven hospitals and two radiotherapeutic institutions was presented. The aim of this study was to evaluate the regional care pathways and determine the performance of diagnostic procedures, lead time, and patients outcomes, based on data from the Netherland Cancer Registry. In this study quantitative data was combined with qualitative data from health care professionals and patients. To interpret the outcomes more adequate, a national benchmark was included. The results of this study revealed that patients who were treated after the implementation of the care pathways, received more positron emission tomography (PET) scans or PET/CT scans. Furthermore, the lead time from the first diagnostic procedure to the multidisciplinary meeting decreased with at least five days. In addition, patients as well as health care professionals mentioned a more efficient and personalized care process after implementation of the care pathways. Based on the interviews with health care professionals, the multidisciplinary meeting was mentioned as being of crucial importance in the collaboration. Although the presented changes in this study were similar to the national developments, qualitative data supports the contribution of a regional oncology network to better structured and efficient care for patients with esophagogastric cancer.

Variation of care and the impact of an oncology network to standardize the patient care pathway and reduce unwarranted clinical variation, was the focus of Chapter 9. In this study more insight was provided in the variation of care for patients with esophageal cancer care within a network of 17 hospitals, including a national benchmark. The aim of this study was to explore trends in variation of esophageal cancer care between clusters of hospitals discussing patients in a joint multidisciplinary meeting. The results of this study showed that although variation in treatment modalities existed between the clusters of hospitals in 2012-2014, no variation was present in 2015-2016, except for patients who received no treatment at all. In addition, the 2-year overall survival of patients receiving treatment with a curative intent did not vary between the clusters of hospitals. Meanwhile, the median lead time before patients started their treatment with a curative intent did vary between the hospital clusters. This study showed that providing insight in variation of care fits into a continuous learning process within an oncology network.

In conclusion, this thesis showed that cancer care pathways can contribute to better patient outcomes. Besides, the development and implementation cannot be isolated from other developments in health care, in fact care pathway should be based on actual evidence-based guidelines and profession-based norms, and therefore outcomes cannot always be assigned to the care pathway alone. This thesis revealed not only effects of care pathways for patients, but also for health care professionals for whom the process of developing and implementing a care pathway contributed to a more pleasant working environment with personal contacts between colleagues within an oncology network. This thesis also underlines the importance of an effective and goal oriented development of cancer care pathways, including the implementation and continuously monitoring using quantitative and qualitative data to provide high-quality and personalized care, based on the needs of patients.