The cause for delays in chemotherapy delivery in ambulatory oncology settings may be multifactorial, according to results of a multisite, qualitative study published in the Oncology Nursing Forum.

While previous studies have determined that hindering the timely delivery of chemotherapy is associated with increased risks of unfavorable clinical outcomes in patients with cancer for whom such treatment is prescribed, less is known about the specific patient-, clinician-, and organization-related factors that lead to prolonged and avoidable delays.

A multiphase study was performed as part of a sequential, mixed-methods project that evaluated communication approaches in Michigan-based ambulatory oncology care practices that were participating in a statewide quality improvement program related to the delivery of cancer care.

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Twenty nine practices took part in the first phase of this study, which involved the completion of paper surveys by staff registered nurses, physicians, nurse practitioners, and physician assistants that consisted of questions relating to “communication satisfaction, practice environments, and communication technology at the ambulatory oncology practices.” In total, 297 clinicians participated in the first phase and the survey response rate was 68%.

Based on survey responses, the ambulatory oncology practices were separated into 4 groups according to level of electronic health record technology use and clinician–clinician communication; those with “high” scores in both categories (group 1), a “high” score in 1 category and a “low” score in the other (groups 2 and 3), and “low” scores in both categories (group 4).

In the second phase of the study, 2 practices from each of the 4 groups were selected for in-person site visits during which chemotherapy infusion-related practices were directly observed, and individual clinicians were shadowed to assess workflow and communication approaches. Recorded interviews were subsequently conducted with 46 clinicians at these practices to elicit their perspectives regarding barriers and facilitators to chemotherapy delivery.

Finally, to determine whether the collective findings were relevant beyond these 8 practice sites, focus groups were conducted with clinicians and clinician leaders at 6 other ambulatory oncology care practices within the same statewide consortium as part of the third phase of the study.

Following analyses of these findings, 4 themes were identified as being associated with delays in the delivery of chemotherapy as follows:

Theme 1

Missing orders and care plan discrepancies for patients with “uncoupled” visits, defined as visits to the ambulatory care center not associated with a physician visit

  • Practices with fewer of these types of delays were found to be more likely to have implemented standardized processes and to have more specific clinician role assignments.

Theme 2

Undocumented or uncommunicated chemotherapy order changes made on the same day as the patient visit to the ambulatory care center that were related to “coupled” physician visits (ie, those occurring on the same day as scheduled chemotherapy delivery)

  • These types of problems were found to be associated with failure on the part of the physician prescriber to write progress notes, as well as a communication breakdown between the physician and the infusion nurse, and were found to be related to organizational barriers in care coordination and the use of communication technology.

Theme 3

Failure on the part of the physician to sign chemotherapy orders in advance in association with physician insistence on “coupled” visits

  • One approach suggested for lessening the likelihood of such a delay was leaving the patient electronic health record open so contact with the nurse would be required before changes could be made by the physician, thus signaling to the nurse that treatment can begin.

Theme 4

Delays associated with waiting for laboratory results

  • The “uncoupling” of laboratory assessments and patient visits was found to lessen the likelihood of these types of delays.

“The results of this study suggest that delays in chemotherapy delivery do not have a singular cause and do not occur in isolation; rather, they are compounded by the multilevel and multifocal organizational structure of ambulatory oncology practices,” the study authors commented in their summarizing statements.”

“To ensure orders are prepared and a patient is ready for treatment, the authors found more practices adopting a model of uncoupled visits,” the study authors noted. Nevertheless, they also mentioned the caveat that “patients’ access to laboratory services in rural areas and dependence on caregiver schedules may affect their preference for appointment uncoupling.”

The researchers further noted that the findings from this study suggest that “clearly defined roles and functions within the ambulatory oncology team, as well as interventions to improve teamwork and communication in ambulatory oncology practices, will facilitate more timely chemotherapy infusion delivery.”


Lafferty M, Fauer A, Wright N, et al. Causes and consequences of chemotherapy delays in ambulatory oncology practices: a multisite qualitative study.Oncol Nurs Forum. 2020;17:417-427.

This article originally appeared on Oncology Nurse Advisor