Year of Publication

2016

Degree Name

Doctor of Nursing Practice

Committee Chair

Dr. Debra Anderson

Clinical Mentor

Dr. Audrey Darville

Committee Member

Dr. Debbie Hampton

Abstract

Purpose: Kentuckians facing a lung cancer diagnosis are at greater risk for care fragmentation due to the complexities associated with the diagnosis, staging and treatment of the disease combined with multiple health disparities such as advanced age, multiple comorbid conditions, low socioeconomic status, geographic isolation, and low literacy levels. Transitioning from primary to specialist care can be especially difficult for these patients. The main purpose of this paper was to determine the feasibility and effect of a nurse-led, multidimensional intervention designed to improve relational (RC), informational (IC), and management continuity (MC) across the primary to secondary care interface, as well as to assess the effect of perceived continuity of care on patient distress levels.

Methods: This study included a sample of 40 patients (20 in the comparison group and 20 in the intervention group). The comparison group received usual care, while the intervention group received an intervention targeted at improving all three types of continuity (RC, IC, MC), beginning with the patient’s first visit to a multidisciplinary lung cancer clinic. Patients in both the comparison group and intervention group completed the Distress Thermometer and Nijmegen Continuity Questionnaire at three separate intervals: at the initial appointment with the specialist, at the specialist appointment following diagnosis and staging, and at the post-surgical follow-up appointment.

Results: Results indicate that this intervention, along with the natural influence of time, may result in improved perceived continuity scores for the intervention group and in improved relational continuity with the PCP for those receiving the intervention. Distress decreased globally over time independent of group placement but decreased in a more linear fashion for the intervention group, though the differences between groups did not reach the level of significance. In addition, older age is associated with lower distress levels and may predict distress levels at time one and time two, but this effect disappears at time three.

Conclusions: A nurse-led intervention to improve all three types of continuity for Kentuckians facing a lung cancer diagnosis was successfully implemented in a sample of 20 patients at a multidisciplinary lung cancer program at an NCI-designated academic cancer center. This pilot study demonstrated that it is feasible to measure continuity in this population in the clinic setting. This research fills a gap in the literature as the only nurse-led intervention designed to improve three types of continuity across the primary to specialty care interface for lung cancer patients who are in the diagnostic, staging, and treatment phase. This research is also unique in that it uses measured perceived continuity as an outcome.

Future Implications: Interventions to improve continuity should be conducted on larger groups of patients with poor prognoses and high levels of distress. Evidence suggests that shared care interventions are appropriate for patient groups who are most likely to benefit, such as patients who are clinically anxious or distressed (Nielsen et al., 2003; Cossich et al., 2004; McCorkle et al., 2009; Johnson et al., 2015). Future studies should also incorporate technological advancements such as teleconferencing between the primary and specialty care teams, and shared electronic medical records such as health portals. Other outcomes in addition to distress, such as resource utilization, that may be sensitive to interventions to improve continuity should also be explored. The role of the APN as a leader for continuity interventions should be explored by performing a cost/benefit analysis.

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