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Background: Standardized cancer patient pathways (CPP) have been adopted as a new policy in several countries, including Sweden. CPPs aim to facilitate patients' trajectories within the health system and improve the timely diagnosis and treatment of cancer. In Sweden, the adoption of CPPs entailed a decision made by decision-makers at the top of the health system; this mandated the use of CPPs by primary and secondary healthcare professionals when assessing patients and addressing their symptoms. Typically, primary healthcare (PHC) is the first point of contact for patients in Sweden seeking care for symptoms that indicate serious illnesses such as cancer. This raises the question of how the adoption of CPPs influenced PHC. Given that the goal was for the policies to work as intended, i.e., to improve early diagnosis and treatment of cancer, understanding the influence of the adoption of CPPs on PHC and its professionals is needed.

Aim: To explore how the adoption of CPPs in northern Sweden influenced PHC organizations and provisions. 

Methods: Qualitative (studies I-III) and quantitative (study IV) methods were utilized. Data were collected using individual and group interviews with participants working in the health system (I–III), and from the National Cancer Register concerning patients diagnosed with colorectal cancer before and after the introduction of CPPs. Additionally, data from electronic health record reviews, from Statistics Sweden, and regarding distance to the hospital for each patient, measured using Google Maps, were collected (IV). The individual interviews comprised participants in national, regional, and local leadership positions (I). The group interviews encompassed nurses and physicians working at PHC in one region (I–III). Interview data were analyzed using the Grounded Theory Method. The quantitative data was analyzed using comparative descriptive statistics and logistic regression (IV).

Results: The actors that adopted CPPs along the cancer trajectory and across the different healthcare levels were not equally involved in developing CPPs. Specifically, actors in PHC, which is the main entrance into care, were barely involved. This might have impacted the initial adoption and subsequent processes. The adoption of CPPs within the Swedish health system involved actors at different organizational levels. Distinct strategies were used to achieve shared goals, although this resulted in insufficient collaboration between the actors at different levels (I). The insufficient involvement of PHC resulted in unintended consequences, such as PHC organizations adjusting routines by themselves. PHC professionals combined existing work as usual with new practices following CPPs to facilitate timely diagnosis and were learning by testing the new ways of working in their practices. Moreover, they continued to manage the unequal relationship to secondary healthcare (II). Applying CPPs in patient encounters entailed challenges for professionals. When determining the seriousness of symptoms, they either relied on their professional competencies or followed symptoms described as alarming by the CPPs. Physicians perceived CPP templates to be easy to apply when their clinical cancer suspicions matched the predetermined criteria; when they did not, a workaround was needed to refer patients to secondary healthcare. Nurses and physicians described sensitively telling patients about upcoming rapid investigation procedures as challenging; for example, they did not want to frighten patients and sometimes tried to safeguard them by not providing detailed information about CPPs (III). The time to diagnosis was reduced for patients with colorectal cancer after the introduction of CPPs, particularly for those who initiated their pathway in PHC. However, for patients with right-sided colon cancer (in the ascending colon), the time to diagnosis did not improve (IV). 

Conclusion: PHC is the entrance into healthcare and is important for early cancer diagnosis. Therefore, it is essential to integrate the perspectives of PHC, e.g., nurses and physicians, when developing and adopting new policies to improve the diagnostic process. Despite the improvement of diagnostic processes that resulted from the introduction of CPPs, challenges remain when specific cancer symptoms are lacking, and clinical suspicions do not always align with the CPP templates.

Bakgrund: Standardiserade vårdförlopp (SVF) i cancervården har införts som en ny policy i flera länder inklusive Sverige. SVF har som mål att underlätta patienters väg genom hälso- och sjukvårdssystemet och förbättra tidig diagnos och behandling av cancer. I Sverige infördes SVF efter ett beslut fattat av beslutsfattare på högsta nivå i hälso- och sjukvårdssystemet. Detta innebar att SVF användes av personalen inom primär- och sekundärvården vid kliniska bedömningar av patienter och hantering av deras symtom. I Sverige är primärvården vanligtvis den första kontakten för patienter som söker vård för symtom som kan innebära allvarlig sjukdom som cancer. Det väcker frågan om hur införandet av SVF påverkade primärvården. Eftersom målet är att policyn ska fungera som det är tänkt, dvs. att förbättra tidig diagnos och behandling av cancer, så behövs det en ökad förståelse för hur införandet av SVF påverkar primärvården och dess personal.

Syfte: Att utforska hur införandet av SVF i norra Sverige påverkade primärvårdens organisation och utförande av vård.

Metod: Kvalitativa (studie I-III) och kvantitativa (studie IV) metoder användes. Individuella intervjuer eller gruppintervjuer genomfördes med personal som arbetar i hälso-och sjukvårdssystemet (I–III). Data samlades också in från det nationella cancerregistret angående patienter som diagnostiserats med tjock- och ändtarmscancer före samt efter införandet av SVF i norra Sverige. Ytterligare data samlades in från patientjournaler, Statistiska centralbyrån och data från Google Maps avseende avstånd till sjukhuset för varje patient (IV). De individuella intervjuerna genomfördes med deltagare i ledarskapspositioner inom den nationella, regionala och lokala nivån (I). Gruppintervjuerna genomfördes med sjuksköterskor och läkare som arbetade i primärvården inom en region i norra Sverige (I–III). Intervjudata analyserades med hjälp av metoden grundad teori. Kvantitativa data analyserades med hjälp av jämförande beskrivande statistik och logistisk regression (IV).

Resultat: Aktörerna som arbetade med införandet av SVF längs hela cancervårdkedjan och genom de olika nivåerna i hälso- och sjukvårdssystemet var inte lika involverade i utvecklingen av SVF. Aktörer från primärvården, som är huvudingången till vården, upplevde att de var knappt involverade. Detta kan ha påverkat det initiala införandet av SVF och de efterföljande processerna. Införandet av SVF inom det svenska hälso- och sjukvårdssystemet involverade aktörer på olika organisatoriska nivåer. De använde separata strategier för att uppnå gemensamma mål, men samverkan var otillräcklig mellan aktörerna från de olika nivåerna (I). Den otillfredsställande involveringen av primärvården resulterade i oavsiktliga konsekvenser såsom att primärvården anpassade rutiner i sin organisation på egen hand. Primärvårdens personal kombinerade sitt vanliga arbete med det nya arbetssättet utifrån SVF för att underlätta snabbare diagnostik av cancer och lärde sig att arbeta på nya sätt genom att testa det i praktiken. De fortsatte också att hantera den befintliga ojämlika relationen till sekundärvården (II). När SVF tillämpades i vården så medförde det utmaningar för primärvårdens personal. När de bedömde allvarlighetsgraden för symtomen som patienten uppvisade förlitade de sig både på sitt professionella omdöme och följde de symtom som beskrevs som alarmerande enligt SVF. Läkare i primärvården uppfattade SVF-mallar som lätta att använda när deras kliniska misstanke om cancer stämde överens med de förutbestämda kriterierna i SVF. När så däremot inte var fallet, behövde de använda sig av alternativa vägar för att remittera patienter till sekundärvården. Både sjuksköterskor och läkare beskrev att det var utmanande att informera patienter om kommande snabba utredningar inom SVF. Till exempel ville de inte skrämma patienterna samt försökte ibland skydda dem genom att inte informera om SVF i detalj (III). Tiden till diagnos förkortades efter införandet av SVF för patienter med tjock- och ändtarmscancer, särskilt för de patienter som startade sitt vårdförlopp i primärvården. Däremot förkortades inte tiden till diagnos för patienter med högersidig tjocktarmscancer (i den uppåtgående tjocktarmen) (IV).

Konklusion: Primärvården är den huvudsakliga ingången till hälso- och sjukvården och är viktig för tidig cancerdiagnos. Därför är det av stor vikt att integrera primärvårdens perspektiv (till exempel sjuksköterskor och läkare) när en ny policy utvecklas och införs för att förbättra diagnosprocesser. Trots förbättringarna av diagnosprocesser efter införandet av SVF så kvarstår utmaningar (i primärvården) när specifika cancersymtom saknas och när kliniska misstankar om cancer inte överensstämmer med SVF-mallarna.

Background: Standardized cancer patient pathways as a new policy has been adopted in healthcare to improve the quality of cancer care. Within the health systems, actors at different levels manage the adoption of new policies to develop healthcare. The various actors on different levels play an important role and influence the policy adoption process. Thus, knowledge about how these actors use strategies when adopting cancer patient pathways as a policy in the health system becomes central.

Method: The study's aim was to explore how actors at different organizational levels in the health system adopted cancer patient pathways. Our overarching case was the Swedish health system at the national, regional, and local levels. Constructivist Grounded Theory Method was used to collect and analyze qualitative interviews with persons working in organizations directly involved in adopting cancer patient pathways at each level. Twelve individual and nine group interviews were conducted including 53 participants.

Results: Organizational actors at three different levels used distinct strategies during the adoption of cancer patient pathways: acting as-missionaries, fixers, and doers. Acting as missionaries consisted of preaching the idea of cancer patient pathways and framing it with a common purpose to agree upon. Acting as fixers entailed creating a space to put cancer patient pathways into practice and overcome challenges to this. Acting as doers comprised balancing breadth and speed in healthcare provision with not being involved in the development of cancer patient pathways for the local context. These strategies were not developed in isolation from the other organizational levels but rather, each level interacted with one another.

Conclusions: When adopting new policies, it is important to be aware of the different strategies and actors at various organizational levels in health systems. Even when actors on different levels developed separate strategies, if these contribute to fulfilling the four domains of inter-organizational collaboration, they can work well together to adopt new policies. Our study highlighted that the application of two domains was lacking, which meant that local actors were not sufficiently involved in collaboration, thus constricting the local use and optimization of cancer patient pathways in practice.

Objective: To compare the diagnostic interval for patients with colorectal cancer before and after the introduction of cancer patient pathways in northern Sweden.

Design: A retrospective study comparing two cohorts (2012 and 2018) of patients diagnosed with colorectal cancer before and after the introduction of cancer patient pathways in 2016.

Setting: Three counties in northern Sweden with large sparsely populated areas and some cities (637143 residents ∼5.1 residents/km2).

Subjects: Patients were included from the Swedish Cancer Register. Electronic health records reviews were performed and linked to socioeconomic data from Statistics Sweden.

Main outcome measures: Differences in the diagnostic intervals, the patient intervals and the characteristics associated with the longest diagnostic intervals and investigations starting at the emergency department.

Results: The two cohorts included 411 patients in 2012 and 445 patients in 2018. The median diagnostic interval was reduced from 47 days (IQI 18–99) to 29 days (IQI 9–74) (p < 0.001) after the introduction of cancer patient pathways in general. Though for the cases of cancer in the right-side (ascended) colon, the reduction of the diagnostic interval was not observed and it remained associated with investigations starting at the emergency department.

Conclusion: Our results indicate that cancer patient pathways contributed to an improvement in the diagnostic interval for patients with colorectal cancer in general, yet not for patients with cancer in the right-side colon.

Implication: In general, cancer patient pathways seem to reduce the diagnostic interval for colorectal cancer but it is not a sufficient solution for all colorectal cancer localisations.

Background: The introduction of new tools can bring unintended consequences for organizational routines. Cancer Patient Pathways (CPP) were introduced into the Swedish healthcare system in 2015 to shorten time to diagnosis and treatment. Primary healthcare (PHC) plays a central role since cancer diagnosis often begins in PHC units. Our study aimed to understand how PHC units adjusted organizational routines to utilizing CPPs.

Method: Six PHC units of varied size from both urban and rural areas in northern Sweden were included. Grounded theory method was used to collect and analyse group interviews at each unit. Nine group interviews with nurses and physicians, for a total of 41 participants, were performed between March and November 2019. The interviews focused on CPPs as tools, the PHC units’ routines and providers’ experiences with using CPPs in their daily work.

Results: Our analysis captured how PHC units adjusted organizational routines to utilizing CPPs by fusing existing practices with new practices to offer better quality of care. Specifically, three overarching organizational routines within the PHC units were identified. First, Manoeuvring diverse patient needs with easier patient flow, the PHC units handled the diverse needs of the population while simultaneously drawing upon CPPs to ease the patient flow within the healthcare system. Second, (Dis) integrating internal know-how, the PHC units drew upon internal competence even when PHC know-how was not taken into account by those driving the CPP initiative. Third, Coping with unequal relationships toward secondary care, the PHC units dealt with being in an unequal position while adopting CPPs instead further decreased possibilities to influence decision-making between care-levels.

Conclusion: Adopting CPPs as a tool within PHC units brought various unintended consequences in organizational routines. Our study from northern Sweden illustrates that the PHC know-how needs to be integrated into the healthcare system to improve the use of new tools as CPP. Further, the relationships between different levels of care should be taken in account when introducing new tools for healthcare. Also, when adopting innovations, unintended consequences need to be further explored empirically in diverse healthcare contexts internationally in order to generate deeper knowledge in the research area.

OBJECTIVES: This study examined whether sociodemographic factors, including distance to hospital, were associated with differences in the diagnostic interval and the treatment interval for colorectal cancer in northern Sweden.

METHODS: Data were retrieved from the Swedish cancer register on patients (n = 446) diagnosed in three northern regions during 2017-2018, then linked to data from Statistics Sweden and medical records. Also, Google maps was used to map the distance between patients' place of residence and nearest hospital. The different time intervals were analysed using Mann-Whitney U-test and Cox regression.

RESULTS: Differences in time to diagnosis were found between groups for income and distance to hospital, favouring those with higher income and shorter distance. The unadjusted regression analysis showed higher income to be associated with more rapid diagnosis (HR 1.004, CI 1.001-1.007). This association remained in the fully adjusted model for income (HR 1.004, CI 1.000-1.008), but not for distance. No differences between sociodemographic groups were found in the treatment interval.

CONCLUSION: Higher income and shorter distance to hospital were in the unadjusted models associated with shorter time to diagnosis for patients with CRC in northern Sweden. The association remained for income when adjusting for other variables even though the difference was small.

Background: The aim was to explore how nurses in primary healthcare (PHC) adjust routines using Cancer Patient Pathways (CPP). CPPs are intended to shorten time to diagnosis but unintended consequences can occur for organizations that utilizes them. Furthermore, in Sweden, PHC is the main entrance into healthcare and nursesas first contact, together with physicians’ are important actors for timely diagnosis.Hence, to explore the unintended consequences when using CPPs in PHC is important since it may impact the process of adaption to CPP.

Methods: Grounded Theory method was used to collect and analyse qualitative data. Six PHC units were included with a variation in size, staff and location. Data was collected through focus groups with nurses and physicians at each PHC unit, for a total of 41 participants in nine interviews.

Results: When previous practices meet new ones, three distinct but connected work routines emerged in PHC and encompassed a dimension ranging from continuing working with existing practice to adapting CPPs in their work. However, two of the work routines were mainly related to nurses and depicted how they continued working broadly with patient needs in the population while adapting CPP to speed up patient flows. Additionally, nurses continued to draw upon their longstanding know-how of prioritizing with alarm symptoms while adapting to work with routines in new ways, while physicians were the ones reorganizing adjusted routines in their units. Lastly, the third work routine generally illustrated physicians dealing with unequal relations in communication with secondary care regarding referral criteria and nurses were not involved in these referrals.

Conclusions: PHC units in our study had not been involved in planning the introduction of CPPs, with nurses excluded in particular. Instead, as our results show, nurses developed their own process to manage using CPPs as a way to adjust to the new procedures, with the unintended consequences influencing their process of adaption. Our study suggests that decision-makers in healthcare could make better use of the know-how within PHC, especially nurses expertise, when developing and introducing new tools such as CPPs.

Background: The aim was to explore how primary healthcare centers (PHC) had adjusted working routines using Cancer Patient Pathways (CPP). CPPs are intended to shorten time to diagnosis, improve access to care and reduce inequality in cancer care. In addition to these intended changes, CPPs have unintended consequences for organizations that utilizes them. In Sweden, PHCs are particularly affected because they are the first and main entrance into healthcare and also important actors of CPP for timely diagnosis. When Sweden in 2015 introduced CPPs, there was an opportunity to explore unintended consequences of using CPPs in PHCs.

Method: Grounded Theory method was used to collect and analyze qualitative data. Six PHCs were included with a variation in size and location. Data was collected through group interviews with nurses and physicians at each PHC, for a total of 41 participants in nine interviews.

Results: Our analysis resulted in a process consisting of three distinct but connected work routines. Each routine encompassed a dimension ranging from continuing working as usual to adapting CPPs in their work. The PHCs continued working broadly with patient needs while adapting to speeding up patient flows. Additionally, the PHCs continued to be in a position of dependency on secondary care while adapting to “easier” referral of patients. Lastly, the PHCs continued to draw upon their longstanding know-how while adapting to work with alarm symptoms in new ways.

Conclusion: PHCs in our study had not been involved in planning the introduction of CPPs. Instead, as our results show, the PHCs developed their own process to manage using CPPs as a tool. The process illuminated their adeptness to deal with new tools and procedures. Our study suggests that decision-makers in healthcare could make better use of the know-how within PHCs when developing and introducing new tools such as CPPs.