title: Introduction: Understanding and influencing multilevel factors across the cancer care continuum.
abstract: Health care in the United States is notoriously expensive while often failing to deliver the care recommended in published guidelines. There is, therefore, a need to consider our approach to health-care delivery. Cancer care is a good example for consideration because it spans the continuum of health-care issues from primary prevention through long-term survival and end-of-life care. In this monograph, we emphasize that health-care delivery occurs in a multilevel system that includes organizations, teams, and individuals. To achieve health-care delivery consistent with the Institute of Medicine's six quality aims (safety, effectiveness, timeliness, efficiency, patient-centeredness, and equity), we must influence multiple levels of that multilevel system. The notion that multiple levels of contextual influence affect behaviors through interdependent interactions is a well-established ecological view. This view has been used to analyze health-care delivery and health disparities. However, experience considering multilevel interventions in health care is much less robust. This monograph includes 13 chapters relevant to expanding the foundation of research for multilevel interventions in health-care delivery. Subjects include clinical cases of multilevel thinking in health-care delivery, the state of knowledge regarding multilevel interventions, study design and measurement considerations, methods for combining interventions, time as a consideration in the evaluation of effects, measurement of effects, simulations, application of multilevel thinking to health-care systems and disparities, and implementation of the Affordable Care Act of 2010. Our goal is to outline an agenda to proceed with multilevel intervention research, not because it guarantees improvement in our current approach to health care, but because ignoring the complexity of the multilevel environment in which care occurs has not achieved the desired improvements in care quality outlined by the Institute of Medicine at the turn of the millennium.
authors.affiliation: Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 6130 Executive Blvd, Rockville, MD 20852-7344, USA. taplins@mail.nih.gov
authors.forename: Stephen H
authors.initials: SH
authors.lastname: Taplin
authors.forename: Rebecca
authors.initials: R
authors.lastname: Anhang Price
authors.forename: Heather M
authors.initials: HM
authors.lastname: Edwards
authors.forename: Mary K
authors.initials: MK
authors.lastname: Foster
authors.forename: Erica S
authors.initials: ES
authors.lastname: Breslau
authors.forename: Veronica
authors.initials: V
authors.lastname: Chollette
authors.forename: Irene
authors.initials: I
authors.lastname: Prabhu Das
authors.forename: Steven B
authors.initials: SB
authors.lastname: Clauser
authors.forename: Mary L
authors.initials: ML
authors.lastname: Fennell
authors.forename: Jane
authors.initials: J
authors.lastname: Zapka
mesh_terms: D003131:Combined Modality Therapy / Q000009:adverse effects / Q000592:standards; D003266:Continuity of Patient Care / Q000592:standards / Q000639:trends; D003657:Decision Making; D019468:Disease Management; D055088:Early Detection of Cancer; D019317:Evidence-Based Medicine; D006297:Health Services Accessibility / Q000592:standards / Q000639:trends; D006801:Humans; D033183:Interdisciplinary Communication; D009369:Neoplasms / Q000175:diagnosis / Q000628:therapy; D010166:Palliative Care / Q000592:standards / Q000639:trends; D010348:Patient Care Team / Q000592:standards / Q000639:trends; D010358:Patient Participation / Q000639:trends; D058991:Patient Protection and Affordable Care Act; D061214:Patient Safety; D018802:Patient-Centered Care / Q000592:standards / Q000639:trends; D010818:Practice Patterns, Physicians' / Q000592:standards; D057285:Precision Medicine; D011787:Quality of Health Care; D012931:Social Environment; D012959:Socioeconomic Factors; D013727:Terminal Care / Q000592:standards / Q000639:trends; D016896:Treatment Outcome; D014481:United States