Figure 1
Tiered care approach of the Accessible Cancer Care to Enable Support for Cancer Survivors model. Routine distress and care needs screening were provided to all cancer survivors before triaging to further follow-up by a supportive care team based on reported levels of care needs.
Table 1
Summary of implementation strategies employed in the Accessible Cancer Care to Enable Support for Cancer Survivors intervention.
| STRATEGY | CFIR DOMAIN | ACTORS AND ACTIONS | TARGET AUDIENCE | TEMPORALITY | JUSTIFICATION | ANTICIPATED IMPACT |
|---|---|---|---|---|---|---|
| Establish a core workgroup to ensure procedural accountability | Organizational (inner setting) | The core workgroup met regularly to discuss implementation challenges and elicit feedback for workflow streamlining. | Core workgroup, clinicians delivering the intervention, service coordinators | Monthly meetings were held with key process indicators reporting to the funder every quarter. | Facilitates iterative feedback and improvement process and brainstorms strategic engagement with stakeholders. | Enhanced feasibility and sustained intervention adoption. |
| Develop educational initiatives | Process | The core workgroup collaborated with the institutional education department to develop informational resources and plan educational activities. | Cancer survivors and caregivers, community service partners | Educational activities were concurrent with intervention implementation. | Promotes awareness of intervention and self-management by survivors and network weaving with community partners through educational outreach efforts. | Improved adherence to screening, increased number of trained community partners, and increased referrals to community services. |
| Strengthen the inclusivity of screening procedures | Individual survivor characteristics, intervention characteristics, process | The core workgroup culturally adapted the screening tool for the local population and translated it into multiple languages. Informational system and trained service coordinators supported a hybrid screening administration mode. | Cancer survivors | Translation occurred before the intervention launch. Efforts to improve the informational system for EMR integration are ongoing. | Targets survivor-level language and health literacy barriers to enhance screening uptake and adherence. | No systematic differences in screening completion rates across survivors of different ethnicities and health literacy levels. |
| Develop standardized, integrated care pathways | Intervention characteristics, process | The core workgroup led the development of standardized care pathways to map evidence-based interventions to all reported problems in the screening tool. | Supportive care team members | Pathways were drafted before intervention launch and amenable to changes following workgroup meetings. | Reduces variation in clinical practice across supportive care team members and provides systematic access to appropriate service referrals. | High responsiveness to survivors reporting high distress levels. |
[i] Abbreviations: CFIR, Consolidated Framework for Implementation Research; EMR, electronic health records.
Figure 2
Overview of the clinical workflow for the screening procedures using the Distress Thermometer and Problem List, discussion during oncologists’ review, and subsequent management of survivors referred to the supportive care team.
Figure 3
Distress Thermometer and Problem List adapted from the National Comprehensive Cancer Network.
Figure 4
Overview of supportive care interventions and a network of community services referrals available for survivors based on care needs.
Table 2
Characteristics of ACCESS model recipients (N = 1853).
| CHARACTERISTIC | N (%) |
|---|---|
| Age, mean (SD) | 60.7 (11.2) |
| Ethnicity | |
| Chinese | 1496 (80.7%) |
| Malay | 186 (10.0%) |
| Indian | 115 (6.2%) |
| Others | 56 (3.0%) |
| Cancer diagnosis | |
| Breast | 1683 (90.8%) |
| Gynaecological | 170 (9.2%) |
| Language preference for screening tool | |
| English | 1444 (77.9%) |
| Mandarin | 385 (20.8%) |
| Malay | 21 (1.1%) |
| Tamil | 3 (0.2%) |
Table 3
A summary of tasks and time required to support screening procedures weekly based on an estimated caseload of 150 survivors per week.
| TASK | TIME REQUIRED | FREQUENCY | TOTAL TIME REQUIRED PER WEEK (MINUTE) |
|---|---|---|---|
| Export a list of scheduled visits in the upcoming week | 30 minutes for all patients | Weekly | 30 |
| Register survivors in the electronic system before DTPL could be disseminated | 5 minutes per survivor | Weekly | 750 |
| Schedule DTPL for the electronic system to trigger a SMS with the link for completion to survivors a few days before scheduled visits | 10 minutes per survivor | Weekly | 1500 |
| Download DTPL responses from the electronic system into a compiled Excel spreadsheet | 5 minutes per download | Daily | 25 |
| Transpose compiled responses into individual responses | 5 minutes per response | Daily | 750 |
| Relay screening results to oncologists in clinics before consults physically and assist survivors with in-person completion of screening tool | Full clinic hours (6 hours daily) | Daily | 1800 |
| Total | 4855 (equivalent to approximately 2 FTE) | ||
[i] Abbreviations: DTPL, Distress Thermometer and Problem List; FTE, full-time equivalent.
Table 4
Screening completion rates among survivors with multiple medical oncology visits during the 18-month implementation period (N = 1259).
| NUMBER OF VISITS IN THE REVIEW PERIOD | COMPLETION RATE | ||
|---|---|---|---|
| <50%, N (%) | 50–99%, N (%) | 100%, N (%) | |
| All survivors with multiple visits | 164 (13.0%) | 412 (32.7%) | 683 (54.3%) |
| 3 visits (n = 171) | 28 (16.4%) | 46 (26.9%) | 97 (56.7%) |
| 4 visits (n = 132) | 9 (6.8%) | 55 (41.7%) | 68 (51.5%) |
| 5 visits (n = 119) | 17 (14.3%) | 35 (29.4%) | 67 (56.3%) |
Table 5
Poisson regression analysis of screening completion rates for survivors with multiple medical oncology visits (N = 1259).
| VARIABLES | UNADJUSTED COMPLETION RATE RATIO (95% CI) | ADJUSTED COMPLETION RATE RATIO (95% CI) |
|---|---|---|
| Ethnicity | ||
| Chinese | Reference | Reference |
| Malay | 0.89 (0.79, 0.99) | 0.85 (0.76, 0.95) |
| Indian | 1.01 (0.91, 1.12) | 0.99 (0.90, 1.10) |
| Others | 1.00 (0.87, 1.14) | 0.98 (0.85, 1.14) |
| Preferred language | ||
| English | Reference | Reference |
| Non-English | 0.96 (0.90, 1.00) | 0.95 (0.89, 1.02) |
| Agea | 1.00 (0.99, 1.00) | 1.05 (0.99, 1.00) |
[i] a Modelled as a continuous variable.
Table 6
Type and frequency of community service referrals proposed to survivors reporting high distress (N = 529).
| COMMUNITY SERVICE | PROPORTION OF HIGHLY DISTRESSED SURVIVORS WHO RECEIVED COMMUNITY REFERRALS BY THE SUPPORTIVE CARE TEAM, N (%) |
|---|---|
| Hospice | 69 (13.0%) |
| Cancer-specific servicesa | 28 (5.3%) |
| Primary care physicians | 27 (5.1%) |
| Community facilitiesb | 18 (3.4%) |
| Social servicesc | 9 (1.7%) |
| Home-based care services | 8 (1.5%) |
| Transport-related services | 4 (0.8%) |
| Exercise programs | 3 (0.6%) |
| Othersd | 6 (1.1%) |
[i] a Includes 365 Cancer Prevention Society, AIN Society, Breast Cancer Foundation, Children’s Cancer Foundation, Singapore Cancer Society.
b Includes community day care facilities, community nursing, rehabilitative centres.
c Includes general, family, financial.
d Includes eldercare, Ambulance Wish, Brave Charismatic, CGH Neighbours, private acupuncture, specialized disabled centre.
Table 7
Acceptance rates of community service referrals and subsequent attendance rates to accepted referral visits.
| COMMUNITY SERVICE | ACCEPTANCE, N (%) | ATTENDANCE, N (%) |
|---|---|---|
| Hospice (n = 69) | ||
| Referred/attended | 58 (81.2%) | 46 (79.3%) |
| Declined | 11 (15.9%) | 9 (15.5%) |
| Unknown/pendinga | 0 (0%) | 3 (5.2%) |
| Cancer-specific servicesb (n = 28) | ||
| Referred/attended | 17 (60.7%) | 11 (64.7%) |
| Declined | 7 (25.0%) | 1 (5.9%) |
| Unknown/pendinga | 4 (14.3%) | 5 (29.4%) |
| Primary care physicians (n = 27) | ||
| Referred/attended | 22 (81.5%) | 10 (45.5%) |
| Declined | 3 (11.1%) | 3 (13.6%) |
| Unknown/pendinga | 2 (7.4%) | 9 (40.9%) |
| Community facilitiesc (n = 18) | ||
| Referred/attended | 12 (66.7%) | 10 (83.3%) |
| Declined | 6 (33.3%) | 0 (0%) |
| Unknown/pendinga | 0 (0%) | 2 (16.7%) |
[i] a Refers to scheduled community visit that occurs after the study review period or the outcome of the community visit could not be traced.
b Includes 365 Cancer Prevention Society, AIN Society, Breast Cancer Foundation, Children’s Cancer Foundation, Singapore Cancer Society.
c Includes community day care facilities, community nursing, rehabilitative centres.
Table 8
Screening completion rates at attended medical oncologist visits stratified by periods of significant COVID-19 events.
| OUTCOME | SIGNIFICANT COVID-19 EVENTSa | |||
|---|---|---|---|---|
| PRE-COVID-19 PERIOD | DORSCON ORANGE | CIRCUIT BREAKER | GRADUAL REOPENING | |
| Attended visits, n (%) | 2048 (93.4%) | 793 (86.3%) | 614 (76.8%) | 4009 (92.3%) |
| Attended visits with screening tool completion, n (%) | 1660 (81.1%) | 512 (64.6%) | 434 (70.7%) | 3173 (79.2%) |
[i] a Defined by the following time periods: pre-COVID-19 lasted from September 2019 to end January 2020, DORSCON Orange with social distancing and mobility restriction measures lasted from February to end March 2020, Circuit breaker (lockdown) lasted from April to early June 2020, gradual reopening phase refers to the remaining time periods.
Abbreviation: COVID-19, coronavirus 2019; DORSCON, Disease Outbreak Response System Condition.
Figure 5
Number of scheduled and attended visits, and proportion of attended visits over the 18-month implementation period when significant COVID-19 restrictions were imposed. (DORSCON = Disease Outbreak Response System Condition, with orange representing severe disease and tightened control measures; Circuit Breaker = lockdown).