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\begin{document}

\title{Clinic Reported Facilitators and Barriers to Pediatric Cancer Survivor
Care Delivery among Survivorship Clinics: A Fishbone Analysis}



\author[1]{Victoria Krauss}%
\author[2]{Ann Mertens}%
\author[2]{Jordan Marchak}%
\author[1]{Regine Haardörfer}%
\author[2]{Lillian Meacham}%
\author[2]{Rebecca Williamson Lewis}%
\author[1]{Robert Wright}%
\author[1]{Oyinda Adisa}%
\author[1]{Apoorva Kommajosula}%
\author[1]{Cam Escoffery}%
\affil[1]{Emory University School of Public Health}%
\affil[2]{Children's Healthcare of Atlanta Inc Aflac Cancer and Blood Disorders Center}%


\vspace{-1em}



  
  \date{May 24, 2024}


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\begin{abstract}
\textbf{Background:} Childhood cancer survivors need regular, long-term
survivor care. The Children's Oncology Group (COG) recommends that
pediatric cancer patients receive ongoing, evidence-based surveillance
for late-effects beginning two years after cancer therapy completion. A
third of survivors are not engaging in long-term survivorship care. This
study assessed barriers and facilitators to follow-up survivorship care
through the perspectives of pediatric cancer clinic representatives.
\textbf{Methods:} As part of a hybrid implementation-effectiveness
trial, a representative from 12 participating pediatric cancer survivor
clinics completed a survey about site characteristics, and a
semi-structured interview on barriers and facilitators to survivor care
delivery at their institution. Interviews were grounded in the
socio-ecological model (SEM) framework and utilized a Fishbone diagram
to identify the root causes of a problem. We ran descriptive statistics
and conducted thematic analyses of the interview transcripts to create
two meta-Fishbone diagrams. \textbf{Results:} Participating clinics
(n=12) have existed for at least five years (mean=30, range= 5-97), and
half (50\%) report seeing 100-200 survivors annually. In the Fishbone
diagram, top facilitators were in the SEM domain of Organization,
specifically with familiar staff (100\%), resource utilization (92\%),
survivorship-exclusive staff (83\%), and clinic processes (83\%). Common
barriers were in the domains of Organization, Community, and Policy
which included technology limits (92\%), scheduling issues (92\%),
insufficient funding/insurance (92\%), and distance/transportation
(100\%). \textbf{Conclusion:} Using the Fishbone diagram was
instrumental in understanding multilevel contextual issues related to
survivor care delivery for pediatric cancer clinics. Future efforts can
develop education, processes, and services to promote cancer follow-up
care.%
\end{abstract}%



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\textbf{Hosted file}

\verb`Fishbone Manuscript Final 12.23.22.docx`  available at \url{https://authorea.com/users/569954/articles/615750-clinic-reported-facilitators-and-barriers-to-pediatric-cancer-survivor-care-delivery-among-survivorship-clinics-a-fishbone-analysis}\selectlanguage{english}
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