Understanding diffusion of evidence-based community cancer care: A case study of network connections in an integrated health system

Abstract

Despite overall declines in cancer mortality in the U.S. over the past three decades, many patients in community settings fail to receive evidence-based, high-quality cancer care. Networks that connect community clinics and academic medical centers hold potential to address these disparities by creating avenues for knowledge diffusion and access to specialty care, but research on networks is mixed and understanding of the underlying diffusion and adoption processes is incomplete. A case study was conducted of a large integrated health system in the Midwest using electronic health record data for 20 patients with young-onset colorectal cancer (CRC) or risk-related conditions. Social network analysis was employed to describe the network and identify connections between providers. Process tracing of patient narratives provided detailed accounts of whether and how network functions led to evidence-based outcomes. Results indicate that the network addressed common barriers to evidence-based medicine (EBM) diffusion and adoption for some but not all patients. In fact, network failures offset benefits or delayed them for some patients, and access to EBM was often provider-dependent. Local specialists displayed higher levels of EBM knowledge and often brokered advice between community primary care providers and specialists in the academic medical center, but information diffusion was sometimes incomplete. Failures in documentation also led to fragmented care coordination and confusion about the best evidence course of care, especially when referrals circumvented local specialists and when patients brokered communication between providers. Full implementation of networks—informed by both network and interpersonal relationship theories—is necessary to leverage their potential to bring EBM information to community providers and increase access to specialty care. In the context of young-onset CRC, this includes increased awareness, opportunities for a mix of lean and rich communication between local providers and academic medical center specialists to determine evidence-based care, coordinated referrals, and systems to document information for all providers involved in care. Through in-depth understanding of how and when this large integrated network operated to achieve EBM outcomes, the current study provides insight into factors that may support or inhibit the ability of networks to provide patient-centered, evidence-based, and coordinated care in community settings.