Pluralistic Task Shifting for a More Timely Cancer Diagnosis A Grounded Theory Study from a Primary Care Perspective
Main Article Content
Abstract
Objective: To explore how cancer could be diagnosed in a more timely way. Design: Classic grounded theory analysis of primary care physicians’ free text survey responses to: “How do you think the speed of diagnosis of cancer in primary care could be improved?” and secondary analysis of primary care physician interviews, survey responses, literature. Setting: Primary care in 20 European Örenäs Research Group countries. Subjects: Primary care physicians: 1352 survey respondents (2013-2016), 20 Spanish and 7 Swedish interviewees (2015-2019). Main outcome measures: Conceptual explanation of how to improve timeliness of cancer diagnosis. Results: Pluralistic task shifting is a grounded theory of a composite strategy. It includes task sharing - among nurses, physicians, nurse assistants, secretaries and patients - and changing tasks with cancer screening when appropriate or cancer fast-tracks to accelerate cancer case finding. A pluralistic dialogue culture of comprehensive collaboration and task redistribution is required for effective pluralistic task shifting. Pluralistic task shifting relies on cognitive task shifting, which includes learning more about slow analytic reasoning and fast automatic thinking initiated by pattern recognition; and digital task shifting, which by use of eHealth and telemedicine bridges time and place and improves power symmetry between patients, caregivers and clinicians. Financial task shifting that involves cost tracking followed by reallocation of funds is necessary for the restructuring and retraining required for successful pluralistic task shifting. A timely diagnosis reduces expensive investigations and waiting times. Also, late-stage cancers are costlier to treat than early stage cancers. Timing is central to cancer diagnosis: not too early to avoid overdiagnosis, and never too late. Conclusions: We present pluralistic task shifting as a conceptual summary of strategies needed to optimise the timeliness of cancer diagnosis.
Downloads
Article Details
The Grounded Theory Review is an open access journal, which means that all content is freely available without charge to the user or his/her institution. Users are allowed to read, download, copy, distribute, print, search, or link to the full texts of the articles in this journal without asking prior permission from the publisher or the author. This is in accordance with the international Budapest Open Access Initiative (BOAI) definition of open access.
References
Rubin G, Berendsen A, Crawford SM, et al. The expanding role of primary care in cancer control. Lancet Oncol. 2015;16(12):1231–1272. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
Scheel BI, Holtedahl K. Symptoms, signs, and tests: the general practitioner's comprehensive approach towards a cancer diagnosis. Scand J Prim Health
Care. 2015;33(3):170–177. [Taylor & Francis Online], [Web of Science ®], [Google Scholar]
Harris M, Vedsted P, Esteva M, et al. Identifying important health system factors that influence primary care practitioners' referrals for cancer suspicion: a European cross- sectional survey. BMJ Open. 2018;8(9):e022904. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
Zeichner SB, Montero AJ. Detecting cancer: pearls for the primary care physician. Cleve Clin J Med. 2016;83(7):515–523. [Crossref], [PubMed], [Web of Science
®], [Google Scholar]
Malterud K, Reventlow S, Guassora AD. Diagnostic knowing in general practice: interpretative action and reflexivity. Scand J Prim Health Care. 2019;37(4):393–
[Taylor & Francis Online], [Web of Science ®], [Google Scholar]
Tavora F, Crowder CD, Sun CC, et al. Discrepancies between clinical and autopsy diagnoses: a comparison of university, community, and private autopsy practices. Am J Clin Pathol. 2008;129(1):102–109. [Crossref], [PubMed], [Google Scholar]
Hamilton W, Walter FM, Rubin G, et al. Improving early diagnosis of symptomatic ancer. Nat Rev Clin Oncol. 2016;13(12):740–749. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
Naeser E, Møller H, Fredberg U, et al. Mortality of patients examined at a diagnostic centre: a matched cohort study. Cancer Epidemiol. 2018; 55:130–
[Crossref], [PubMed], [Web of Science ®], [Google Scholar]
Davidoff F, Dixon-Woods M, Leviton L, et al. Demystifying theory and its use in improvement. BMJ Qual Saf. 2015;24(3):228–238. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
Harris M, Thulesius H, Neves AL, et al. How European primary care practitioners think the timeliness of cancer diagnosis can be improved: a thematic analysis. BMJ
Open. 2019;9(9):e030169. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
Rose PW, Rubin G, Perera-Salazar R, et al. ICBP module 3 working group. Explaining variation in cancer survival between 11 jurisdictions in the international cancer benchmarking partnership: a primary care vignette survey. BMJ
Open. 2015;5:e007212. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
Oliva B, March S, Gadea C, et al. Gut feelings in the diagnostic process of spanish GPs: a focus group study. BMJ Open. 2016;6(12):e012847. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
Om lärande, prioriteringar och ekonomiska aspekter. Effekter av satsningen på standardiserade vårdförlopp i cancervården. Slutrapport del 2, 2019. [On learning, priorities and economical aspects. Effects of the drive on standardised cancer care pathways. Final report part 2,
. https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/ovrigt/2019-4-1.pdf. (accessed June 29, 2021). [Google Scholar]
Glaser BG, Strauss AL. The discovery of grounded theory: Strategies for qualitative research. Chicago: Aldine; 1967. [Google Scholar]
Petrazzuoli F, Vinker S, Palmqvist S, et al. Unburdening dementia - a basic social process grounded theory based on a primary care physician survey from 25 countries. Scand J Prim Health Care. 2020;38(3):253–264. [Taylor & Francis Online], [Web of Science ®], [Google Scholar]
Sandén U, Nilsson F, Thulesius H, et al. Cancer, a relational disease exploring the needs of relatives to cancer patients. Int J Qual Stud Health Well-
Being. 2019;14(1):1622354. [Taylor & Francis Online], [Web of Science ®], [Google Scholar]
Sandén U, Harrysson L, Thulesius H, et al. Breaking the patientification process -through co-creation of care, using old arctic survival knowledge. Int J Qual Stud Health Well-Being. 2021;16(1):1926052. [Taylor & Francis Online], [Web of Science ®], [Google Scholar]
Burström L, Starrin B, Engström ML, et al. Waiting management at the emergency department - a grounded theory study. BMC Health Serv
Res. 2013;13:95. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
Thulesius HO, Scott H, Helgesson G, et al. De-tabooing dying control - a grounded theory study. BMC Palliat Care. 2013;12:13. [Crossref], [PubMed], [Web of Science
®], [Google Scholar]
Thulesius H, Grahn B. Reincentivizing - a new theory of work and work absence. BMC Health Serv Res. 2007;7(1):100. [Crossref], [PubMed], [Google Scholar]
Glaser BG. Theoretical sensitivity: Advances in the methodology of grounded theory. Mill Valley (CA): Sociology Press; 1978. [Google Scholar]
Glaser BG. Basics of grounded theory analysis: Emergence vs. forcing. Mill Valley (CA): Sociology Press; 1992. [Google Scholar]
Glaser BG. Doing grounded theory: Issues and discussions. Mill Valley (CA): Sociology Press; 1998. [Google Scholar]
Glaser BG. The grounded theory perspective: Conceptualization contrasted with description. Mill Valley (CA): Sociology Press; 2001. [Google Scholar]
Glaser BG. The grounded theory perspective II: Description's remodeling of grounded theory methodology. Mill Valley (CA): Sociology Press; 2003. [Google Scholar]
Glaser BG. The grounded theory perspective III: Theoretical coding. Mill Valley (CA): Sociology Press; 2005. [Google Scholar]
Glaser BG. Doing formal grounded theory. Mill Valley (CA): Sociology Press; 2007. [Google Scholar]
Woolley AW, Fuchs E. Collective intelligence in the organization of science. Organization Science. 2011;22(5):1359–1367. [Crossref], [Web of Science
®], [Google Scholar]
WHO: Task shifting: global recommendations and guidelines. Geneva: World Health Organization, 2008. [Google Scholar]
McCallin A. Pluralistic dialogue: a grounded theory of interdisciplinary practice. Austr J Rehabilitat Counsel. 1999;5(2):78–85. [Crossref], [Google Scholar]
Malterud K, Aamland A, Fosse A. How can task shifting put patient safety at risk? A qualitative study of experiences among general practitioners in Norway. Scand J Prim Health Care. 2020;38(1):24–32. [Taylor & Francis Online], [Web of Science ®], [Google Scholar]
Blythe A. The structure and organisation of primary care” p.4. in Blythe A, Buchan J. eds. Essential primary care. UK: Wiley-Blackwall. 2016. [Google Scholar]
Nicholson BD, Goyder CR, Bankhead CR, et al. Responsibility for follow-up during the diagnostic process in primary care: a secondary analysis of international cancer benchmarking partnership data. Br J Gen Pract. 2018;68(670):e323–e332. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
Hamilton W. The future of diagnosis in general practice. Br J Gen Pract. 2020;70(696):319–320. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
Riva S, Mazzocco K, Pravettoni G. Better outcomes for cancer patients using telemedicine: health-related quality of life (HrQoL) and empowerment. In Tele- oncology. (pp. 23–37. Cham: Springer. 2015. [Crossref], [Google Scholar]
Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Educ Theory Pract. 2009;14 Suppl 1 (Suppl
:27–35. [Crossref], [PubMed], [Google Scholar]
Brodersen J, Schwartz LM, Heneghan C, et al. Overdiagnosis: what it is and what it isn't. BMJ Evid Based Med. 2018;23(1):1–3. [Crossref], [PubMed], [Google Scholar]
Hippisley-Cox J, Coupland C. Symptoms and risk factors to identify women with suspected cancer in primary care: derivation and validation of an algorithm. Br J Gen Pract. 2013;63(606):e11–e21. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
Klemenc-Ketis Z, Terbovc A, Gomiscek B, et al. Role of nurse practitioners in reducing cardiovascular risk factors: a retrospective cohort study. J Clin Nurs. 2015;24(21-22):3077–3083. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
Maier CB, Aiken LH. Task shifting from physicians to nurses in primary care in 39 countries: a cross-country comparative study. Eur J Public Health. 2016;26(6):927– 934. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
Pisu M, Henrikson NB, Banegas MP, et al. Costs of cancer along the care continuum: What we can expect based on recent literature. Cancer. 2018;124(21):4181–
[Crossref], [PubMed], [Web of Science ®], [Google Scholar]
Birtwistle M, Earnshaw A. Saving lives, averting costs: an analysis of the financial implications of achieving earlier diagnosis of colorectal, lung and ovarian
cancer. UK: Cancer Res. 2014. [Google Scholar]
Hultstrand C, Coe AB, Lilja M, et al. Negotiating bodily sensations between patients and GPs in the context of standardized cancer patient pathways - an observational study in primary care. BMC Health Serv Res. 2020;20(1):46. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
Thulesius H, Håkansson A, Petersson K. Balancing: a basic process in end-of-life cancer care. Qual Health Res. 2003;13(10):1353–1377. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
NEJM Catalyst. What is value-based healthcare? https://catalyst.nejm.org/what-is- value-based-healthcare/. (accessed: 29 June 2021. [Google Scholar]
Porter ME, Teisberg EO. Redefining Health Care. Boston, Mass: Harvard Business School Press; 2006. [Google Scholar]
Varela J. Looking for Value-Based Community Health. Abstract Book of the 89th EGPRN Meeting, Vigo - Spain, 17-20
October 2019. https://www.egprn.org/file/7e2f297c-a9e0-42af-8a2e-cb30b04dfcdd/Abstract-Book-of-the-89th-EGPRN-Meeting-Vigo-Spain-17-20-October-2019.pdf. (accessed: 29 June 2021). [Google Scholar]
Christensen C, Waldeck A, Fogg R. How Disruptive Innovation Can Finally Revolutionize Healthcare. A Plan for Incumbents and Start-Ups to Build a Future of Better Health and Lower Costs; Clayton Christensen Institute for Disruptive Innovation, 2017. Available online: https://www.christenseninstitute.org/wp- content/uploads/2017/05/How-Disruption-Can-Finally-Revolutionize-Healthcare- final.pdf (accessed: 29 June 2021). [Google Scholar]
Glaser B. Experts versus laymen: a study of the patsy and the subcontractor. Mill Valley (CA): Sociology Press 1972. [Google Scholar]
Robertson FC, Lippa L, Broekman MLD. Editorial. Task shifting and task sharing for neurosurgeons amidst the COVID-19 pandemic. J Neurosurg. 2020 Apr 17:1-3. doi: 10.3171/2020.4.JNS201056. Epub ahead of print. PMID: 32302998; PMCID: PMC7164328. [Crossref], [Google Scholar]
Holtedahl K. Early diagnosis of cancer in general practice: a manual. Berlin Heidelberg: Springer-Verlag, 1990. [Crossref], [Google Scholar]
Holtedahl K. Challenges in early diagnosis of cancer: the fast track. Scand J Prim Health Care. 2020;38(3):251–252. [Taylor & Francis Online], [Web of Science
®], [Google Scholar]
Ewing M, Naredi P, Zhang C, et al. Identification of patients with non-metastatic colorectal cancer in primary care: a case-control study. Br J Gen Pract. 2016;66(653):e880–e886. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
Disbeschl S, Surgey A, Roberts JL, et al. Protocol for a feasibility study incorporating a randomised pilot trial with an embedded process evaluation and feasibility economic analysis of ThinkCancer!: a primary care intervention to expedite cancer diagnosis in Wales. Pilot Feasibility Stud. 2021;7(1):100. [Crossref], [PubMed], [Google Scholar]
Feiring E, Lie AE. Factors perceived to influence implementation of task shifting in highly specialised healthcare: a theory-based qualitative approach. BMC Health Serv Res. 2018;18(1):899. [Crossref], [PubMed], [Google Scholar]
Bg G. Naturalist Inquiry and Grounded Theory. Historical Social Research/Historische Sozialforschung. 2007. Suppl, 114-132. http://www.jstor.org/stable/40981073.
(accessed June 29, 2021), [Google Scholar]
Olsen DS, Fevolden A. Gradual transition. Bottlenecks and task sharing in diagnostic imaging. Oslo: the nordic institute for studies in innovation. Res
Educ. 2013E;46. [Google Scholar]
Gessessew A, Barnabas GA, Prata N, et al. Task shifting and sharing in Tigray, Ethiopia, to achieve comprehensive emergency obstetric care. Int J Gynaecol
Obstet. 2011;113(1):28–31. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
Robertson FC, Esene IN, Kolias AG, Global Neurosurgery Survey Collaborators,
et al. Global perspectives on task shifting and task sharing in neurosurgery. World Neurosurg X. 2020;6:100060. [Crossref], [PubMed], [Google Scholar]
Robertson FC, Lippa L, Broekman MLD. Editorial. Task shifting and task sharing for neurosurgeons amidst the COVID-19 pandemic. J Neurosurg. 2020 Apr 17:1-3. doi: 10.3171/2020.4.JNS201056 [Crossref], [Google Scholar]
Wright EO. Metatheoretical foundations of Charles tilly’s durable inequality. Compara Stud Soc History. 2000;42:458–474. [Crossref], [Web of Science ®], [Google Scholar]
Andersson KP, Ostrom E. Analyzing decentralized resource regimes from a polycentric perspective. Policy Sci. 2008;41(1):71–93. [Crossref], [Web of Science ®], [Google Scholar]