Tracing the potential of networks to improve community cancer care: an in-depth single case study

BACKGROUND: Despite overall declines in cancer mortality in the USA over the past three decades, many patients in community settings fail to receive evidence-based cancer care. Networks that link academic medical centers (AMCs) and community providers may reduce disparities by creating access to specialized expertise and care, but research on network effectiveness is mixed. The objective of this study was to identify factors related to whether and how an exemplar AMC network served to provide advice and referral access in community settings. METHODS: An embedded in–depth single case study design was employed to study a network in the Midwest USA that connects a leading cancer specialty AMC with community practices. The embedded case units were a subset of 20 patients with young-onset colorectal cancer or risk-related conditions and the providers involved in their care. The electronic health record (EHR) was reviewed from January 1, 1990, to February 28, 2018. Social network analysis identified care, advice, and referral relationships. Within-case process tracing provided detailed accounts of whether and how the network provided access to expert, evidence-based care or advice in order to identify factors related to network effectiveness. RESULTS: The network created access to evidence-based advice or care in some but not all case units, and there was variability in whether and how community providers engaged the network, including the path for referrals to the AMC and the way in which advice about an evidence-based approach to care was communicated from AMC specialists to community providers. Factors related to instances when the network functioned as intended included opportunities for both rich and lean communication between community providers and specialists, coordinated referrals, and efficient and adequately utilized documentation systems. CONCLUSIONS: Network existence alone is insufficient to open up access to evidence-based expertise or care for patients in community settings. In-depth understanding of how this network operated provides insight into factors that support or inhibit the potential of networks to minimize disparities in access to evidence-based community cancer care, including both personal and organizational factors.