Enhancing Cancer care of rural dwellers through telehealth and engagement (ENCORE): protocol to evaluate effectiveness of a multi-level telehealth-based intervention to improve rural cancer care delivery

Abstract

Background: Despite lower cancer incidence rates, cancer mortality is higher among rural compared to urban dwellers. Patient, provider, and institutional level factors contribute to these disparities. The overarching objective of this study is to leverage the multidisciplinary, multispecialty oncology team from an academic cancer center in order to provide comprehensive cancer care at both the patient and provider levels in rural healthcare centers. Our specific aims are to: 1) evaluate the clinical effectiveness of a multi-level telehealth-based intervention consisting of provider access to molecular tumor board expertise along with patient access to a supportive care intervention to improve cancer care delivery; and 2) identify the facilitators and barriers to future larger scale dissemination and implementation of the multi-level intervention.

Methods: Coordinated by a National Cancer Institute-designated comprehensive cancer center, this study will include providers and patients across several clinics in two large healthcare systems serving rural communities. Using a telehealth-based molecular tumor board, sequencing results are reviewed, predictive and prognostic markers are discussed, and treatment plans are formulated between expert oncologists and rural providers. Simultaneously, the rural patients will be randomized to receive an evidence-based 6-week self-management supportive care program, Cancer Thriving and Surviving, versus an education attention control. Primary outcomes will be provider uptake of the molecular tumor board recommendation and patient treatment adherence. A mixed methods approach guided by the Consolidated Framework for Implementation Research that combines qualitative key informant interviews and quantitative surveys will be collected from both the patient and provider in order to identify facilitators and barriers to implementing the multi-level intervention.

Discussion: The proposed study will leverage information technology-enabled, team-based care delivery models in order to deliver comprehensive, coordinated, and high-quality cancer care to rural and/or underserved populations. Simultaneous attention to institutional, provider, and patient level barriers to quality care will afford the opportunity for us to broadly share oncology expertise and develop dissemination and implementation strategies that will enhance the cancer care delivered to patients residing within underserved rural communities.

Trial registration: Clinicaltrials.gov , NCT04758338 . Registered 17 February 2021 - Retrospectively registered, http://www.clinicaltrials.gov/.

Keywords: Consolidated framework for implementation research (CFIR); Precision medicine; Virtual molecular tumor board.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2021. The Author(s).

Figures

Fig. 1

Location of Participating Vanderbilt Health Affiliate Network sites serving rural counties within the VICC Catchment area. This figure illustrates the study’s catchment area throughout Tennessee and Mississippi, including a distinction between rural versus non-rural counties. Each number represents the location of one of nine participating hospitals through the Vanderbilt Health Affiliated Network (VHAN), including seven through the Baptist Memorial Health Care Corporation and two through Ballad Health. This figure was created by the authors specifically for this clinical trial protocol

Fig. 2

Conceptual Framework: Implementation of Evidence-Based Cancer Care Delivery to Rural Populations via Telehealth. This figure illustrates the conceptual framework for implementation of the multi-level telehealth intervention to bring evidence-based comprehensive cancer care to patients in rural counties in Tennessee. The white blocks on the left indicate that we will evaluate the clinical effectiveness of delivering a multi-level telehealth intervention to rural hospitals to improve cancer care delivery, consisting of 1) provider-level access to tumor board expertise that incorporates disease, patient, and molecular tumor characteristics, and 2) patient-level access to a supportive care intervention (Aim 1). The dark gray block on the top right outlines the intervention outcomes. The gray blocks in the middle illustrate domains and subdomains of the CFIR that we will examine during intervention delivery to identify barriers and facilitators to future larger scale dissemination and implementation of the intervention (Aim 2)

Fig. 3

Study schema. VICC, Vanderbilt-Ingram Cancer Center; HOPE, Hereditary and Oncologic Personalized Evaluation; CTS, Cancer Thriving and Surviving intervention; EMR, electronic medical record

Fig. 4

Recruitment and surveys conducted at the provider level and patient level per study phase. The action and particular survey that will be completed by both the provider and patient for the Enrollment Phase, Tumor Board Phase, and Post-Intervention Phase is illustrated. MTB, molecular tumor board; CTS, Cancer Thriving and Surviving