1 THE FAMILY FO LOW- P R R L TO I ORPORATE LO -TERM FOR AD LT HILDHOOD R URVIVOR I 0 PRA Tl b uzann Liu ni B T r it lumbi a In titut lumbia 2 0 echn 1 gy, 2 BMITT DIN P TH R IN : FAMILY UNIV RSITY PRA TITI F N RTH RN BRIT! H Augu t 2015 © uzanne iu , 201 5 IR M R L MBI T F R 2 b tract fthi pr J t Th purp 10 hildr n ' rp rate th adult guid lin a t n I g n h are hildh d an r f th lit ratur a r th qu r up guid lin ndu t t h Jp an pra ti ti ng-t 1m [i 11 int pnmar Ul n nur ar pra tic r th rch qu [! r c mpr h n i ti n. h finding f t b pnm ar pr , and th t a multi - mp n nt appr a h w uld b th t impr \ lini cal pra tic . Th r id 111 rp ratl ar h al 11 h m d 1 f are w uld b an and a\\ ar 11 -up ar dcm n trat d th at adh r n m t ffi ti hildh ti n: h f th e hildr 11 ' hildren' 11 n I g log d that a multi -di iplinary, c n ultant led r hared ith r pect t the I ng-ten11 [i 11 w- up f r . Pati nt, pr id r and y t m relat d barri r t the u e of th amincd and di u ed. The pr 0ec t concl ud ed with p cific recommend ati on D r nur practiti oner to appl y t th eir pra ti ce t improve the 1 ng-term follow -up for hildhood cancer urviv r . 3 cknowl d I atharin uld lik t thank m hill r RN , c M mmitt ,J uld al n urag m nt, and rin Wil fl r th ir in r dibl pr ~ I ment P- ~; and nM upp rt and fl r th 1r p rt t. lik t th nk m hu band , fri nd nd fami l \ h h w ndl h I am t m 11 gr t ful t !I r upJ rting m in m gradu at tudi . 4 Ta bl e of ont nt b tra t ...... .. . ....... .. ... ......................... . ... ................. .. ..... .. ................ ..... . .. 2 kn I dg 111 nt ......... . ................. . .......................................................... . h an r n d it r a tm n t. .................................................. 12 ............................................................................... 1 uid lin H ............................................. 2 1 u Th Imp rtanc r ning urviv r. f hildh uid lin 1m pi m ntati n .................................................................... 24 Th Prin ip1e f Imp I m nt ti n 1 n ................................................. 24 Pati nt, Pr id r and tern R 1 t d an-i r ............................................. 25 M del f TF ar ......................................................................... 2 t hapt r 2: M th d .......................................................... ........................... 3 1 Tab! 1........................................................................................... 3 Tab1 2 ......................................................... .................................. 40 hapter : Finding ................. .................................................................... 41 hapt r 4: Di cu i n ................................................... . ............................... 65 a k of Pr id rand Pati nt Kn \\I dg .................................................... 65 Mod I of ar .. ................ .... .. ... . .... .. . ... ............................................ 6 Role of ur e Practiti oner in TF for ......................... .................... 7 1 hapter 5: Recommendation .................. ................................. . .. .................... 73 trategie Targetin g Pati nt ............. .. . .. ............... ... ........ . .. ............... .... T' trategie Targ tin g Provid r ... ....... ..... ......... . ... .. ... . ... .......................... 7 trateg ie Targetin g y tem Barrier .... ..... ...... . . ..... . .......... . . ..................... 5 onclu ion ......... .................. ..... ...... ... .... ............ ....... .. . ............................. 7 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 9 Appendix I .... ..... ........... ..... .... .... . .... . ... ......... . .. .. .. .. . . ...... ............................ 99 Appendix II ......... .... .. ... .. .... .. .. . ... . . .. . ...... . .... .... . ........................................ 107 Appendix 111 ..... ... . ... .. . ... .. . ... ... ........... ........... .. .. . .. .. . ................................. 11 5 Introduction famil . an f an r m hild an b d a tating D r b th th p ti nt n l th r n t nl put th hild ' li[i lnJ a rd , but it i a I treatm nt and t ntiall li~ u h a hair 1 hil th r m hanging id efil t . n t d vel p until th b th h rt and 1 ng- t rm id diagn i and th tr atm nt th a hild h ha appr priat II 11 -up II r thi r hip rat id hild re [,0 t ar acut , d. ecau e f adulth d ith in t n ith cane r, th ir p t ntial t impa t all f th eir futur n . hi hi ghlight th imp rtan urv1 th b n diagn r h alth car M di al ad an m ia t d f n uring c rdinat d are and pe ializ d p pulati n. m nt m an r tr atment ha f 0% II r p di atri malignan i t pak, & Wallac , 20 12 · c tti hInter ll egiat r ult d in an v rall fi ( dgar, uidelin rthwick, -yea r uffin , Marciniak],20 13). eventy fiv p rcent f hildr n diagno ed wi th cancer n w li e for at lea t 10 year after diagno i (Bhatia & Meado w , 2006). Th e CUlT nt utcome ar a ub tantial improvement when compared with th 1960 , when nl y 25% f ch.ildren urvi ved more than five year aft r receiving a diagn i of cancer (Edgar et al. 20 12). Due to the e improved outcome , there ha been an increa e in th e number of adult who are childhood cancer urvivor (CC ) (Edgar et al., 20 12; uh et al. , 2014 ). The e patient compri e a specialized population for whom additional creening and urveillanc by their health care provider i reco1m11ended , and thi creening i d pendent upon their individual cancer hi torie ( hi ldren' Oncology Group [C ], 2013; Edgar tal., 2012; Suh tal. , 2014). The additiona l creening that i recotru11end ed i e entia] t fa ilitat early 6 ti n f th p t nti 1 1 ng-t nn d t m r a d ri k qu Ia 201 , f e pite th h ha diatri an r d n t r P P ) ffinger tal ., [! r u P ptibilit t man guid lin dif~ rent i en the[! cu the r ). , many adult mm nd ed r enmg tt ndan f thi patient th C miliarity [primary th m 1 e id e ar at athan t al., 2 1 ar a gr up at high ri k th ir an r trca tm nt , nur i e a way t practiti ner rdinate th th ir car . f thi pap r i fa mil nur e practiti n r practice, wh n u ing the context f primary care. The care of be appr priate pr vid er in a imil ar (20 13) d e id ntify P a appr pri ate pr vi der ~ r . When u ing the term P P, it i to allude to tudi e that included P P a a gr up of participant , which no literature that pertain hi h db a d ith the intent that ther P P may al directing the L TF rei aring ~ r thi p pul ati n mu t d and th r pr P, it i , uh tal. , 2 , 2 l , uh t al., 20 1 ). r commend d ere ning practi term itt, 2 rem am ith th 0 ; tm nt, [! r h l, 2 12 · uh t aL 2 14 . p pulati n in I ng-t nn [! 11 id r n r tr d guid lin n d r W id, Ku hni , car pr f metime includ d olely to the care delivered to by P . However there i P . Therefore, in thi paper when di cu sing data from tudie petiaining to P P , it i with the und r tanding that NP areal o considered primary care provider ( RNBC , 2013b). The complexity involved in combining the individual pediatric diagno of with the type of trea tment received in order to devi e a plan £ r urveillance could b overwhelming to any NP who ha not pe ialized in oncology. The CO ought to reduce that complexity and wa the fir t organization in North comprehen i merica to relea 7 guid lin that utlined th n 1run ndati n r ( d gar tal. 2 12). h id dgar t al. 2 12 . h nt a alid t guid lin tting t fa ilitate th £1 1m ti n n nada, P wh In th ir p diatri 1 g tr atment h n ractiti n r ar al adult and ha b b t uit d t a tran iti n compl ). hi1dh d an plan n in th clinical u r m t fth n h ar nc th d hea lth ca r hi ch can al k r u1 oft n pr ent ache £1 r h e hav b c m e uini er, J ng, Kamp 1 auw h alth i ue that requir may b to m mpl t d ( ranck t al. 2 12). pati nt a a tran iti n ba k t pnm r care mg r t a!., , 201 e year ( d P ith a rang tma , 200 8; [need and hi ch pediatri c nc 1 g1 t p cializ d (Blaauwbr ek et a!. , 2 0 ), thu a pnmary care tting i m re uitabl In the conte t fprimary care, P ar able to dev 1 pal n g- term re lati n hip w ith C , a they provide ongoing care in a familiar etting for any h alth c nc m , and wh ere CC can eliminate the tigma of being a cancer patient (Blaauwbr ek t al., 2008 ; al., 201 0) . Since it will be P P who addre as ilia et the vari u health i sue of th e e patient , it i appropriate that they al o continue to monitor them and order the appropriate creening in follow-up to their cancer diagno is and treatment ( inger et al., 2013) . uffi ci nt knowledge on the part of P P regarding the recomm nded to offer evid nce-ba ed surveillance practic al. , 2013). G guideline is therefore crucial in order t any of their patient who ar ( uh et 8 lt fl r a during m rk d in p di tri . lh childr n a ra ti h ha e b n tr t d £1 r r gi t red nur th t 1 b n ar an r. h t ha n d t th ati n w nder d hat it uld b lik r th p ti nt t u h tting with a ng-tenn [feet uld imp t th ir futur ar nd h h uld r id . In Januar 2 15 , funding f fl ur dif:D r nt ti r a appr f ar ll [ th d fl r and [ th ir ith wh m th qu , ti n generated the impetu hi h thi pr ~ect ha be n b d. n w pl an th at ugge t tratifying hi ch i dep nd ent n b th th e xp rti e f the pro id rand the ri k and/ r e i ting id e effect Agency, n.d.). in nt r th pnmar ca r th f th ir futur -up that mplet d. I al ti n d h t b gin e pl ring th lit ratur up n int on tm nt h ung ag . I qu h m th rap and r di ati n r p n ibilit r and fl 11 f g t am, th t it timul t d my thinking in r gard mpl car d fl r hundr d nd ha mu h upp rt, h r rdinat d thr ugh u r p di tri pertl t din th m peri need by th e an er P fit int b th ti er on (primary care, 25 r m re 1 w ri k pati ent per year and low ri k recall) and p ibly tier tw primary care with pecialized kn wledge, 35 or more n w moderate ri k pati ent per y ar and m derate ri k r call of thi provincia l program, it i important that they ar familiar with the guid eline , a th e e contain the recommendation for thi pati nt population (B gency, n.d.). Although anc r in B will now be organized into the e variou tier ther are many patient living in rural areas that will fit into ti er one or ti r tw , and th refore an e aminati n f the literature to determine which m del of care i mo t appr priat i till warranted. dditi nail , alth ugh thi pr gram will benefit both pati nt and pr vider , gap related t kn wl dge and u of 9 th gUI till e i tin lin r and th mu t be addre d ath n t 1. ,201 uh t 1. , 20 14). f thi pap r L t h purp the qu ti n: H an h 111 a nmary ar G ll -up and u1 illan T intr du th pap r, ill b di cu d, a m [! 11 b t in rp . 1 b care [! r adu lt ti n [! r th la k f ut the ignifi ance [ [! r i t r gard ing rtaining t m que ti n ill b for . Th ddre cd. hi will be f th m th d u d [! r the int grati e litera ture ummarizing th outlin d and ynth ized in lyzing pl r d. kgr und in[! m1ati n a hap t r pl nng nd guid elin arri r th t . b 1 and impli [! r nm ar h in luding a tabl th ra ti urr nt kn db a di u ndu t lit ratur r e t th earch finding wi ll be hapt r 4, [! 11 w d b a di cu i n f their ignifi a nee in hapt r 5. Recorrun endation that target th r ducti n r eliminati n f p tenti al banier t u ing the guid lin in the clinical etting will b of£ red in recmrunendation includ e trategi practic that hapt r 6. The e P can mploy t increa e the u f ere ning in their clinica l etting. Finally c ncluding tatement that umm arize there earch findings will be made. 10 Background thi numb r in r a ,4 appr u 1 b thr ing, th b rgan a a dir mpli ati n p r nt t lum i ( riti h UI f th pati nt are m at ri k [! r futur id r ar n t a ar th health f a h r ,2 , and ati n p t ntiall in t re ult f th int n i et al. 2 10) . If pr p 11i n fth a mpn ing alm t ery n r tr atm nt th rccei ed a f th r r ning that an id ntify th mm nd d hildr n ( a ill ill be at ri k, r ulting in increa d m r idity [! r thi pati nt p pulati n. Th fir t ti n f thi cancer m rder t pr hapt r d rib th van u tr atm nt id a ba i b r und er tanding the ha elate ffl ct with th af[i t e i al, p ch I gi a!, r ial [! r childh d ay in which the e tr atm nt ca n ral b dy y tem . Late effect can b d fin ed n equ n e f the di ea e r treatment that can app arm nth or even year aft r tr atm nC (Bradwell, 2009, p. 21 ). History of Childhood Ca ncer urv ivor and E tabli hment of Guideline In 1948, idney Farber wa the fir t to ugge t a treatment regime fl r ch ildhood cancer (Shad, 20 15) . ince then, long-te1m urvival ha been increa ing, with the mo t rapid improvements fir t noted in the 1970 with the di covery that multiple chemotherapy agent u ed in combination produced greater succe than treatment with a ingle chem therapy drug (Dixon-Wood et al., 2005; Meadow , 2001) . After the di covery of multi-agent therapy, the number of urvivor increa ed graduall y and expon ntially up to the 75- 0% of children that now urvive 5 year or more after being tr ated for cancer (Bhatia & Mead w , 2006). 1 th mid-1 70 c n 111 2 01) . h rtl aft 1 ard , it Mad c nfinn th nn ti n b tw c mpn d guidelin p pulati n , a n T reatm ent of r pr th r imilar d cument hildhood Th rear of malignancy ( pital utilize pr I1ium fth memb r fth r 1 a, ed th ir initial er i n f ndu ted ~ r thi pr j ar h t, th e nt th fir t publi h d guid line Ii r thi patient r r trie d ith an earlier publi hing dat . ancer f difD r nt tr atment empl y d in pediatric cancer ; th m may b u ed either al ne or 111 H (2 1 a d nth lit ratur re r 1 a d in 2 that lud d m n , ary t re n r tr atm nt and a c n nd an th ~ r t n lat th ral in tituti n gu id lin tm n t b g n t tr a n t dthatm re ubj n lat M ad futur fth ndu tr and indi idual in tituti n LT r th lat m f mbinati n with thcr tr atment d pending n th e typ , n .d .). reatm nt in utlin d by th an ( r ntr , the 8 hildr n' hildrn· Hopita l,20 13) . urgery1 a common therapy that can be u ed to either treat or di agn e c rtain cancer ( , n.d . ). In orne ca e the trea tm ent will include only urg ry while in other , radiation may be u ed first to hrink the tumour o it can then be urgica lly remo ved ( , n .d .) . hemotherap y i another fonn of therapy u ed in the trea tment of childhood cane r ( G, n .d.). Thi involves the admini tration of dru g eith r intravenou ly, ubcutaneou ly, intrathecally, intraperitoneally intracavitarily, intramu cularl y or orally to treat pediatric malignancie ( 0 , n .d.). A oppo ed to urgery r radiati n which targ t can r ell in one area ch emotherapy work throu gh the entire body to eliminate and prevent th growth of new cancer cell ( , n .d.; Dixon-Woods, Young, & H n y, 2005) . Th rear many 12 diffi r nt h m th ra m m ti n f h m therap dru g th t i m 111111 nd ti n r g rding th tr ating , and th r1ain diagn hm gi diagn i , and a h n.d.; tr atm nt 11 n ar kn n-W t al., d h m beam radiati n, wh r th radi ti n 1 , n.d.). pla thi th r p m nt and d ag , n.d.). fhigh n rg r diati n t 111V t c mm n t liminate can er c 11 u ed i tenned e t rna! p ifi all t rg t d t a parti ular par1 fth b dy dmini f th radiati n b am or n t i a c mple d m hi h i d tem1in db th p n d fr db ffi ti , n.d.). n a pr t n it and l ngth f Radiati ( m m ti n t t rg t dif r nt ph m that r u n.d .. u ti n an r r m di m red, m ur ment are mad t n ure adequat , n.d. ). Wheth r a child receive radiati n d n a h child' diagn i . and heth r a parti ular ancer i treatabl by radiati n therap i d t nnined by a radiati n nc I gi t in c n ultati n with the multi-di ciplinar t am If a hi ld · cancer i r . n.d.). 1 tant t chem the rap r if the pr gn tran plant i another treatment that can be c n idered ( extremely high level child' bone marrow ( p r, a tern cell , n.d.). Thi treatment all w fi r f chemotherapy, termed myel ab lative, becau e it eradicate th e G n.d.). A tern cell tran plant i then infu ed intravenou ly aft r thi chemotherapy to re tore the patient' bone marrow o th may have a functioning immune sy tern after completion of the cancer tr atment ( , n.d. ). The tern cell ar collected fr m a donor ither periph rally or fr m th e d nor ' b n marr w, and thi i termed an allogeneic tran plant ( , n.d.). lfth child' anc r diagno i d e n tin the bone matT w, the patient' own tem c 11 may be c II cted and then re-infu d t r tore 13 and thi f tT n lant i kn an c r and it r atm nt th ir b n man na n ut 1 g u tran plant n.d.). Late Effect of hi1d nd ub equ ntl und rg ing tr lea Ul t r [! und in th tum ur r gi tri 71 in[! nnati n a ut n er p ti nt and th ir trca tm nt and ii und that th int n it (t c rrelati n rI fr m tv h pita! in the nited iti , durati n and r d . g r t a!. (2 ) u yd l9 el : 1 el nc pati ent h d und erg ne rd ing t thr ri k h m th rap , 1 nt datab a e c nt ining detailed ith th numb r [ lat tratifi d th m urg r al n 1 11 n et al. (20 1 ) ing id th t child at ri k [i r d tm nt an It patient had b n trea t d ith I thr e pati ent had rec i cd chem therap and 1 d e ranial iiTadiati n, an d I radiati nth rap y ( ept I w d e cranial irradiati n) and/ r m gath erapy uch a hi gh d c ch moth rapy an r b ne marrow tran plant (BMT) . The findin g indi ca ted th at l vel three pati nt rep rted m relate effect than I v I tw pati nt , and thereii r the e re ult al o demon trated a po itive c ITelation b tween tr atment inten ity and late ffect ( i er et al. 2006). The incidence of late effect m cancer urv1vor i greatly increa ed compared t the incidence of the ame conditi n in the gen ral populati n. effinger eta!. (2006) recei ed que tionnaire from 14,3 72 cancer urvivor and c mpar d the e to qu e tionnaire recei ed from 3,846 ibling of the urviv r . urvi r were alm t thre time m r likely t exp rience ovarian failure, m re than t n time m re likely to ha they w re ab ut fifty tim c ng ti e heart failure, at greater ri k f ha ing a maj r joint r plac d, and the w re 14 m r lik 1 t n tim r ult illu tr t th th n n a lll hi h th ntinu diagn c n lud d. it lf h id n -b t nd n nd a f h m f li~ I ng 1m t a p ti nt' qu I it d and arl d t ti n and tr atm nt f u h lat P P ar R aman 2 0 gam, ffin g r tal. 2 0 pia m f~ t r th tr atm nt c r pr ti f~ ct Hadd , Mo h r, ). lin e guid lin n i t f ri k-b that ar n indi\ idu al" ba d id n pnn p1i d re n p ~ r , 2 1 ). T h y ar r trea tm nt ( f urvei ll an e pra ti cc determined by and n 20 l ). he d mm nd d cr nmg pra ti e um nt al empha iz r comm nd ati n int nded t r pl ace r that inn way ar the ny finding th at ar id ntifi ed by a P P during the hi t r and ph , 20 1 ). h re[i r , the guideline r lea d by th are m ant t be u ed in c nj uncti n with th e a e ment f by P P . pecifically, 51 % f th r c mm ndati n are deri ed fr m the H&P e am alone, 20% c n i t of the H&P in additi n to a di agno ti c tud y (£ r e ampl e bl oodw rk r imaging), 26% are compri ed of r curr nt laborat ry r ther di agn appropriate interval , and 3% of the urveill ance guide!in 201 3). B LTF hi ldren' Ho pi tal i a member of the to urv ivor , their treatment are ba ed n ti c te ting p rform d at rec mm nd n creening ( 0 . and although it doe not pr prot co l (8 ide hi ldr n · H pi ta l. 201 3 ). Goal of the COG guideline . Th recommendations. ir t, the id ntifi four epara te goa l rela t d to their fo llow-up guid line are de ign d t n our·age hea lth 15 fl r f h lth pr m ti n ( thr ugh apr t n i m fth h n aring £1 r patient ( d d £1 r 11 g f R gi t re l h pr id ng ing m nit ring f th h th mp an 1at ti f£1 t that a lth f ] g in, thi £1 1111 pati f ). fth r r ma p n n imilar t th fir t t g p 1 , th e i , and h alth pr m ti n nd pre cnti n f with thi third intenti n t d th fa i1itat the early l tecti n f ti n m nt and di gn ith their ugg mpha iz f p di atric m ali gnancy. t and injury ar m a c rdan r ening prac tic , th P P to implement arly int r enti n £1 r identified late ffl t . cong1uent with the fl urth ti n h u1d utili z the guid line t u hm nit 20 13a) . Finally, h alth (201 a , and th f h a1th a illn h 1. g al i mtrr r d . lum ia [ f t bj 1 hi h m ha iz 1 f th nd g 20 1 a) . tmp rtan P in , 2 (R (2 1 ) h pe t a i t hi final g al i al P c mpet ncy r ga rding health pr m ti n and preventi n f illnes and injury ( RNB , 201 a) . Intended users of the guideline . The for u e as follow-up for the care of C a ert that their guideline are intended with the exception of follow-up of the urvivo r' primary disease (COG, 20 13). Practitioner deemed appr priate by the follow-up creening of CRNB S are Phy ician , (2013b) delineate tho e a s ssi tant (C ment and diagno tic te tin g procedur within the cope of practice for NP in B and imaging li ted in th P and Phy ician to conduct , 2013 ). The that are and th e majority f the a e m nt , lab t ting guid elines (2013) are clearly within thi cop . 16 Magn ti R un nt ar nan Imaging MRI) i a di gn 2 1 P mg n ur p g1 n ul t r mm nd d d h t radiati n hildh ,a aD r m 11ti ith a p i li t t t th r P P , u h a famil ph R 2 I ,2 1 p ti nt r quiring th r mng pr th r diati 11 r n adjun t t m mm graph II r d can r tr atm nt aring II r ithin th ithin mm 11d d II r pati nt wh f imagin g i re rd mm nd db ur that i n t t fr m ith r h m th rap [[! r a t MRI i r ha . hi ti m 11 h n id ring th te t will n ed t edur , a it i n t ithin the c pc f ,2 1 b . th e th r cr cnm g ll f pr cti c II r a p P in R 201 b) . reation of the guid lin e . ba ed drew up nth pa t 20 p rD rming a mpl ete ar h e id nee up n hi h th guid elin e w re f medi ca l literature, whi ch wa c mpil ed by the arch u ing theM dlin databa e al o retrieved fr m bibliographie of elect d artie! , 2013 ). Refer nee were to br ad n the earch, and me f the e included article that w re publi h d m re than 20 year pri r t the earch ( 2013 ). The proce s for the election of the e older article not de cribed in the docum nt. A even memb r ta k force appointed by the reviewed there earch, and ba ed on thi re earch and a previou guideline writt n by the National ancer Network, a draft practice guideline wa developed for LTF omprehensive for in 2002 ( 2013). The draft wa then ubjected to review by experi in variou field oncology, behavioural cience and patient advocacy, and the draft wa modified ba ed upon their reconunendation ( ,2013). uch a nur ing, ub equentl y by 17 hr uid elin e gra din g. grad d a rding t th 1 rit rja in the guidelin mm ndati n b th f upp rting vid n r pre f reg rding availabl at th tim . nt ar ing le h gradi ng f c n en u by an e pert panel n the trength f upp r1 found in th lit rature D r ach particular ere nin g rec mm nd ati n ( 201 ). High le el e id n that in lude either hi gh qu ality defin d a cat g r 1; it c ntr 1 r and 2B compri e e idence fr m a e r p rt , ca experience ( , 20 13) . ateg n e 2 , n n-analyti c tudi and c lini cal h rt tudi e ( en f upp rting litera ture , 2013 ). Any r c mmendation that in ol e a ignifi cant di cr pancy 111 op1mon (cia ified a category 3) would either be delet d or revi ed by the panel of exper1 o that the lowe t level of e idence repre ented in the actual category 2B ( , 2013 ). uch di agreement typically inv 1 e u gge ted recmnmendati n ; howe er, the encompa sed. guideline would be (20 13) did not xp lain pe ifi all y r mng hat th e 18 Barri r to of th e uid lin Th 201 id ntifi lini al in th it u h t h lp d l rmin th F br H nl ur m mb r , nd m nit d tat ummar 1 nl (P pi fth f charg t th ~ du ning and ati n, 2014) . rt G r I entitl . 11 I ). are I c t d in th e a pati ent dditi nall , m rd r t utili e the P mpl t d mu h ~ e in titu ti n th t ar urr nt m mber rgani za ti th tim b. th pati l; nt pedi atri gu id eline c ncem th e c t- An th r banier that rn a afD t the uptake f the effecti ene f their r comm ndati n . p n rev1 w f the lit rature, it i ev id ent that th ere f the rec mmend ed in ufficient data that p cifically evaluate the c t-effecti en 0 r athan t al. , 20 13; P pl ack et al. , 20 14 ). one I 1 m 11 pr ti e Gr ill an va il ab l fr k t al., 2 14 . r quir d, V\hi hi n t ur ar 11 di a! Pra ti c 1 p d an intern t t ha de !uti n, th n ti n [! r h ' rt n uming [! r th m t b urn nt in rd r t d t nnin th pr p r 2 mm nd ( 111 e nl h t uld b ' it d r quired t r urn nt a b mg n unt th tm tting. p rti n fth lf p ti nt t ting t r th 1 ngth fit d creening practice (Wong et al. , 2014 ). effecti vene of the 0 ne tud y that did evalu at th co t- recommendati n regarding ech cardiography fo und that a decrea e in the recommend d creening frequ ency re ulted in a decrea e in c t without a corre p nding decrea e in health benefit (Wong t al. 2014 ). How repr ent only one ingle tudy e aluatin g on tudi e are ne ded t determin whether or n effe tive. he lack f certainty concerning the c cifi er, thi re ult ere ning ra tice an many m r recommendati on ar actu all y co t- t- [[! cti n f the 19 r n [! r th r lu tan n th r r mm nd ti n rna fpr lin the gui id r t u W ng t 1. 2 14 . uid lin I and Kingd mar a! llkn diatri m li gnan t ntra t th mm nd ati n ta li h d r nand ffing r, 2 1 . h ( kinn r f th guid lin pra ti etw en th publi h d b th guid lin dir cting th for u th hi t ry f ti n mpar nd ar ub f th t th rec mmended f pa ti n t . 11 cti me f the D publi h d clini ca l t ent , 20 1 ). They b th pr pert-r c mm nded urv illan pra tice D r 20 1 ,. Difference . There areal o e eral differenc that ari guideline . The d cum nt . he targ t d cane r ( in a wide vari ety of healthcare faciliti and the IG ith am ar t b dir t d t a p guid lin ba ed and nt [! r p ti wmg an 1mp rtant imilarit a it identifi ,2 m--veillan [! ll nit d u d in th guid lin . ral imilariti ulati n [! r 2 1 guid lin guid lin ' th In additi n t th whi h ha ly, th e ide e id nc - great p tential '2 013). when comparin g th G guideline (20 13 are u ed intern ationall y and are recommended to all of orth Ametica, while the I N guideline , in contra t, are national in nature ince they are employed olely in the nited Kingdom ( IG , 2013 ). The I guideline were developed after the reconunendation wer doe n t pecify an applicabl age rang :[! r it target popul ati n, it doe offer tat that h uld be at lea t tw y ar p t tr atment b [! re th guid line ar appli d t their ituati n. 20 In than 24 1 t ar fa g t diagn thi th d finiti nth ( al diffi r d b t m din th databa lit r tur carch nd m th d f rc i w e t mlnllTil Z bia ( rib d in thi ar h d th lit ra turc in fi e e r h, the nc the guid lin e ,a 2 utiliz d r er cr in an attempt p rt ind pend nt r v ral tim rth pr eding 2 f 2 1 , had r cd rcle ant ar h findin g nl y fr m th e t nti all limiting appli abl re arch data. preceding nine m d h v b n pr ll a p rfi nning n Intern t a mpl t d, th tudi f ach f th guid line h li teratur guid lin gn 2 1 in th d nth ntr t t th pap r. In t di i , and a b ing t dur utili h lit ratur than mg nywh r fr m 1 fi un th t th lit r tur d fin ntra t th f th re mm nd ati n pr gu ideline . F r amp! , th e I id din th fa il ed t pr and liver fun cti n a well a h aring and i i n te ting guid eline were n t pre ent in id r c mm end ati n fo r renal kinner & effin ger 20 13). It i uncl ear whether the I N had dete1mined that the evid enc wa n t trong en ugh t ju tify recommendation pertaining to liver function, vi ion and hearing. The I identify a need for more re earch n the effect (20 13) doe f cancer treatm nt in childr n on renal outcome , o that may be one potential rea on for the e clu ion of recomm ndation regarding thi b dy y tem. Within the G guid lin , creening for cataract , renal and liver function contain 1 vel one evidence which i th guid eline ( 2013). This la t fact indicate that th are more c mJ r hen ive in compari n to the I tronge t eviden e cited wi thin th r enmg pra ti e guid eline . ugge ted by th 2 al fi r th th mm nd th t high ri k r umul ti anthr r du ardi gram rna f ba h r n t th mg/m 2 r ti ent ampl , rega rding h ha r r p tient at 1 lin , the fr qu nc nthr [ ,2 ryfi dt mpar d t b th 1 ). e1 2- than 2 dl h ha id mg/m 2 and r n ra iati n t th gr t r th n 2 lin d ardi gram h t il pr andi r t 1., 2 am r ardi th in th am unt f dif:D r n ardi gra m n t nl n th d g h t n k, r [ . In c ntra t, the f nthra cline and wh th er d h t r di ti n, ut n the gc [ th patient at initial cancer mm nd ati n r g rding h cardi gram , 20 1 ). diagn In additi n t r (2 1 ) un 1 pati ent r gardi ng a h alth y liD tyl ugge t that pr m king and incr a ing and healthy ea ting. In rec mmendati n by th ar mu h m r d tail d. The uch a decrea ing ntra t, the c un guid line d crib type of x rei , uch a aer bic e erci e, that ar appr priate for a well a indicating that certain high int n ity activiti lifting should be avoid d indefinit ly (C contained within the 0 with ca rdiac effect , uch a wre tling and heavy weight plan for P with much more guidance when and pro iding ad ic and education to pati nt . F uture guid elin e . A ne d t cr ate w rldwide tandard forth LTF ackn wledged by the hi ldh repre entative fr m both the d ancer the , 2013). The increa ed detail and pecificity guideline would provide they are developing their LTF llin g uid line Har and the There ha e been ef:D rt put forward to de i mzmg of wa r up ( hi h in lud ) in 2010 ( ki1m r & effing r, 201 ). uch new guidelin , and in lud th 22 lla al nd nd ur p , Jap h t d till . Thi initi tiv till in th d t hildh an r nd va lu ati on f th d . Th an th n ptimi7 I ( kinn r w rk in pr nd th th H nn ni Lmg an r Uld lin m path Int mati n u1 f r p rtin g.. R dit rial ind p nd nee, larity and pr (Th llaborati n, 2001 . The d involvement (201 and the guideline guid clin guid lin ntati nand c pe and purp 1 em nt (Th gr e d mai n c r d 7 % n c p and purp e, 67% n takeh ld er 1% on rigour of devel pment, 67 % on clarity and pre entati n, 63% on 2001 ). The full AGRE valuation for the e guidelin Recommendation . i en the ab e compan are found in oll aborati n, ppendix I and II. n, my ugge ti on ba don th two wid ly u ed creening guideline w uld be to utiliz the guid line in the urveillance of guideline , the red llab rati n, 200 1). In applicability, and 50% on the edit rial ind pend nc domain (The Agree analy i of th ti e guid lin e pr , 2 15) . h .G r c r d 9% in appli cability, l % in rig ur f elopm nt and 92% in tak hold r in contra t the r up, 2 15) . uid lin I 00% in th gr urr ntl r up at thi tim e pertain t I i an in trum nt th t .. \ a lu at pm nt nd th qual it ith 1guid lin gl lm II nn mllng L 1 v lu at d b th th - t he ffin g r, he nl guid elin and R rdin ting r d ing th f ffin g r 2 1 kinncr m n m nt ta g f.G r d b th br rth nd fi r gl bal ppli ati n and b p rt 2 l ur u fr m ur p , P n ar f th r ti n G . Until the development f global tandardized guideline are cunently th m t r gu1arl y updat d and detailed 23 ar th gUI n th t h uld guid diti nall ppr riat £1 r lini al u au th mm nd d that th t th r nmar pr m t £1 r th pat! nt t mall ind p nd ntl n How to e th uid lin B £1 re u ing th guid lin , th in th clinica l P mu t btain recei ed, their do e and r ut (2 I ) tting. tr atm nt umm ary, 2 13· id e the date f ca ncer f radiati n and d e , wheth er the patient underwent a BMT ( inc thi parti cular treatm ent c me , 201 3). h n fall hem th erap medi cation f admini trati n, all fi eld a graft er u h t di ea e and o teonecr 11 a int rpr t the cancer hi t ry f the pati ent and the tr atm nt recei ed ( diagno i , th pati nf dat of birth and e . nam a m d tail ed in£1 rmati n fr m hi a than et al. , 201 ; inger t al. , 201 ). Th e d cument pr pr cedure ( p n th t the r her patient. Thi in£1 rmati n 1 m t ft n ~ und n th pati nt hi h includ db ur ut ffi e d main gu id lm that h uld b u db ar th c th guid line It a r d h1 gh fll1 gUJd lm dm guid lin n t arc targ t d t the gUJd lm With th lf d 2 1 ppr ·' h the gUJd lin and rn a m ar t th pa11i ularl ar upd t d v nlin ( mg r tal. 2 1 r h nid ntif ingth P u i ), and the nam e ith pecifi c ri k uch fall r 1 ant urgical nee thi informati n ha been btained from th pati nf treatment ummary heet, their previ u record , or fr m the pati ent hirr her If, th guideline can be uti lized t dir ct their care ( , 201 ). Th guid eline are n t int nd d t be u ed until at 1 a t tw year £1 11 win g the c mpl etion f cane r trea tm nt, in e be£1 re 24 that tim th pati nt i ing [t 11 ill till b r , 201 ; L ndi r tal. , 2 04 ). ( r i tw m that th ar p The Importance of cr emn Th anadian an r h rit ri n [t r n R t tr atmen t ( ed- urv1 or f ci t , th m n hildh d n (Ame1i ati nal an 1g [ I], 20 15) . h r In titut in all lini urc nt r, 2 1 ). an r n n ], 2 1 · n dian I mph ize th 1m ancer ociety, 2 15; rtanc n and m anagem nt f late ffe t . imilarly, b th th oci ty and identif and urveillanc f late ef£ t a unp rtant r a pecialized population. 11 thre f regular rea e arly m rtality and t th earl r ti n f 1 g and th -up ar D r follo -up and ere nin g [! r thi p pulati n in rder t d arl d t m anada i [t r th imp ati gi t fr m th ir pediatri -up anadian ndary malignancie a well a n ure anc r cr en mg n [t r c ntinu d [! 11 w- up in thi f the e group indicate that each p ati nt h uld be tratified into a ri k group according t their cane r hi torie , and th at the frequency of creening hould be based on the ri k category to which they bel n g (A , 20 13; anadian Cancer Society, 2015; NCI, 2015). Primary care prov ider are directed to the C G guidelines to determine their patient' ri k category and th e a sociated recommended screening practices (ASCO, 2013· Canadian Cancer Society, 2015; CI, 2015) . Hi torically there is low attendance of CCS in follow-up care and clinic (Blaauwbroek et al., 2008). Unfortunately, most adults in BC who are CC are n t fo llowed by PCPs who are familiar with their health 1isks (MacDonald, Fryer, McBride, R oger , & Pritchard, 201 0) . Additionally, although there is on mall survivorship clinic in Vancou r, it is under-funded and has limited resources (K. Goddard, personal cmnmuni cation, Augu t 25 th [! 11 1 pr -up tr t gi D r th pati nt peciall ali nt in thi mce. Guid elin e Implernenta tion Impl m nting hi t rically b n a id n -ba d guid lin pr int pra tice i n t imp! and it ha (M rri lark n, 200 · am clu· der et al., 2009) . and up t date in[! rmation that ha been inc rp rat d int 1ractice guid elines d id n not guarant e adh r n b pra titi n r , nd in fac t, th re tend t b much re i tanc in the m dical fi ld t practice hange , d pit vid n -ba n 2009; Dam hr d r t al., 200 ). hat i , lark s d r c mm ndati n (M rri & en thee i tence ft h high t quality upp rting a practice \ ill n t tran lat dir ctl y int it uptak int practice. e id enc T he Principle of Impl em entation cienc The tudy of how b t t implement tud y finding int practi c i kn wn a implementation cience (Dam chroder et al. , 2009), and inc rporating the principl es of this discipline will facilitate th u e of the G guideline by NPs in th e clinical etting. Implementation cience compri e a specific approach whereby major barri ers to implementing interventions are addressed and byte ting new method to id enti fy, und erstand and overcome these barriers (Sturke et al. 2014 ). The Promoting Action on Re earch Implementation of H ealth Services (P ARIH ) framework is a widely accepted concept in the fi eld of implementation science, and it emphasizes three key concept : evidence, context and facilitation ( tetler, Dam chroder, Helfrich, & Hagedorn, 2011). Research, clinical experience, patient experience and evaluati f the 1 cal context all comprise the evidence component of implementation cience (Rycroft-Maione et al. , 2004; Stetler et al., 2011 ). The conte t component include 26 pti nt n tw rk ) ultur th r t (ph i al 1 ad r hip and 2011 ). Finally, th c n kill a 11 a ial ultur 1, tru tural aluati n R cr ft -M al n th impl m nter ' indi idual ro l and pt f fa ilitati n in and m aint nanc [! rim lem ntati n f th interv nti n p cifi c trat gi (Rycr ft-Mal n et al. , 2004; t tl r t al., 20 11 ). he ted in th R hapt r . trategi ugg f imp! m nt ti n the appli ati n f th principl di u d in the inding and Pati ent, Provid er and 1 cu (20 10) found that m hould b pr t i n pnn iple wi ll be vi lent in th rti I that c an p tenti all y addr nee t th guidelin w ill b hapt r . tem R la ted Barri er P ati ent related barrie r . where£ 11 w-up ar t 1., 2004 ; t tl r et al., n ignifi ant baiTi r t T [ i in regard to id d. Ma da , H ribe, Kat , K jima, and T uru awa ur i or w uld prefer t ha their £ ll w-up care at the arne facility in which the were treated for their malignancy. ften the e are p edi atri c centre o it may not pos ible or appropriate for the am e healthcare team to coordin ate th e LT U care of CC once such a patient ha becom e an adult (Blaauw broek et al. , 2008 ; Maeda et al. , 2010; Michel et al. 2009) . The reason po tulated for the de ire of CS to be treated at the same centre as they were for their primary di ea e is the clo e et of relat ion hip that tend to build between p ediatric cancer patients and their health care team during a traumatic time for the patient (Maeda et al., 2010). When seeking care for their follow-up treatment, it is natural that many CCS would prefer to be seen by the team of profe sionals who ha cared for them in the past and whom they tru t (Maeda et al., 201 0) . How ever continued evaluation in a pediatric c ntr may not promote normal psychological development, as the e patients are no longer children (Maeda 27 et al. 2010; Mi bel tal. 2 ). and man nl n pedi tri pr ati nt d n t rc id can r pati nt in rec 1 d treatm nt £ r their prim r di £ 11 -up car m d 1 h uld th re£ r b th n t a imity t ntr £ r h r th pita! 20 l ). n alternati e ill b di cu d furth r in n id r d and th n fi r th inad quat m ti nal trauma incurr d during the tim t al. , 2007 ; a ill a wanting t reli e th t al. , 2 1 ; ark painful m m n c f f th ir initi al di gn , J nkin on, , m ay be r lated t car b ma a and tr atment ( lett M ann 200 ). t riffi th , Kin ch, id ll w-up car remind d f thi diffi ult tim in th ir li e ( a ill a et al. , 20 l ; Parke pati nt ar cti n . cond r a th th r i dditi nall ft n want t a a cancer patient ( impl m n lett et al., 200 7; Blaauw br ek t al. , 200 8; Park for t al. , 200 8). The e ti gm a f bein g labell ed ith their li e and p a t th an important factor to con ider when c n id ering LTF th ey ar n t t al. 200 8). Thi s i a the de ire to m ve beyond their dia gno i ha the potential to affect both the etting and the provid er th at would be mo t appropriate for LTFU care. Follow-up care by a P may be a viabl e olution to tran ition CCS back into primary care and this will be further explored in th e Di cussion and Recommendation Chapters . A final reason patients who have survived childhood cancer may not acce s LTFU may be because they are unaware of the importance of doing so (A lett et al. , 2007; Blaauwbroek et al. , 2008 ; Nathan et al. , 2013) . Up to 70% ofCC receive little to no information regarding the late effects of their malignancy and treatment and that lifetime creening may be neces ary (Blaauwbroek et al. , 2008) . Many tudi r porting the view of S show a concunent lack of, and a desire for education about the late effects a ociated 28 dgar t al., 2 12 · ith ha ing a hi t ry fa p diatri n1ali gnan M ing r tal. 2 1 ) a kn w1 dg that if 1 ll an tal. , 2 1 · uh tal., 2014). n t a are fthe imp 1ian e f1i:D tim u illan initiati e . her for i 1o f th c guid lin int linica l pra ti b ere ning D r f u1 eyed ucc meri an P P r p rt d t orth f the n the pari fth pati ent, ide th r c mmended uh et al., 20 1 ). e athan et al. (2 1 ) that they familiar with th r c mm nd ati n put D rward by th with the reconunendati n f ful implementati n f th 1 ck f kn n II und t hav inad quat kn al. (20 13) al o D und that the ur ri ing ifth r Ia k f kn wl dg and th imp rianc a than t al., 201 ; ing ret al. 201 rth ar . Provid er related barri r . imil ar t P P hav al th nit h uld n t b gr 1 t th F Dr ig et 1. 2012 · than 10% ere very . uh et al. (20 14) and a th an et m ri c an phy ician they urv yed were n t familiar . Re arch h w that pati ent desire pr vi der who are familiar with their di ea e and their treatment and who can recommend evid ence-ba ed creening practices that have been tailored to their ituati n (S inger et al. 20 13 ). Although not all of the ere earch re ults specifically a sess the knowl edge of describing the lack of adequate L TFU care for CC P , previou data acros North America allow the extrapolation regarding a lack of familiarity with the COG guideline to these provider , a they share a similar scope of practice with physicians when caring for CCS . Most CCS who do seek care attend follow-up in a primary care setting rather than a specialized LTFU clinic (Casilla et al. , 20 l 0) . As previou sly m entioned, BC offer limited :D llow-up in LTFU clinics, therefore follow-up in primary care would be a via bl e option (K. Goddard, per onal communication, August 18, 20 15). Studies have hown that primary care 29 lini d n t ar fl r larg numb r ithin th lini f nd it ma n t b fea ibl fl r th pr t car fl r u h p F undati n fl r Medi al Pra ti ialized pati ent ( ri dman t al., 200 ; du ati n, 2 14). Ther fl r tw main fact r that affl t the abilit and a lack f d tail d plan fl r ith pati nt p n en the i1npl m ntati n f th ntribute t inadequat fl 11 w-up pre u m dical re rd and a la k ntati e of th : a lack t f wl d ge d ficiencie that affl c t typ t al., 2 rdinati n bet f hall ng ( rd ur fth en pr 7) . P. car e fl r ifficulty in retri v m g ider are p rva 1ve 1s u e lett tal., 2 07 · ing ret al. , 2013 ). If r' origina l diagn ry difficult to creat an appropriate creening chedul ( When providing L TF ar id r 1 int pra tic at the 1 el [the [ f a P Pi unabl t obtain accurat re it can be h additi n t p ti nt nd pro ider an1 r , y t m bani r al that are r pr . It i th h ar guid lin y tern related barri r . at th pr id r i and treatment, ,2013) . pati nt , the funding model can al o have a erious impact on patient care. Thi i e peciall y alient when organizing the complex creening and survivorship plan that are e ential to ongoing fl llow-up of C .A survivorship plan is a document that describes the recommended creening procedures and their suggested frequency based on the individual patient' s cancer and treatlnent history (Singer et al., 2013) . In a fee-for-service practice for example, where the emphasis is on the number of patients seen (Newcomer, Gould, Page, Donelan, & P erkins, 2014), the e specialized patients might not receive the detailed as e sments and recommendation that are necessary for optimal care. At the sy tem level, it is a lack of coordinated care and ha mg an appropriate funding m del conducive to the time-con uming nature of caring for C affect the implementation of the OG guideline into clinical practice (Frayne, 20 12) . that 30 Models of LTFU are Many dif£ r nt m d 1 £ r th £ 11 b ing urvi th p r hip clini p pulati n (Fri dman t al. 2 0 c rdinat db a a multi-di ci lina1 ffer 11-r und d and c car tal. , 2007; Bhatia c n i t f th arne r 1nan ar n th n . Th ha be n ugg t d ne f f thi pm1i ular patient d f th tru ture f u h [! 11 w-up hi ch pr ~ r ach th rand riedman et al., 200 ). nother m d 1 imilar t mn care g1 er ntr id ntre ~ r r hip clinic th tabli hment f tr n iti nal car M ad w , 2006). malignancy; howe er, th y d n t r Transitional care centr ifi all n ir nm nt in f ar that ha b n ugg t d i th ( f . In thi m d 1 ar i directed by an nc 1 gi tan P ( ri dman t 1. 200 pr vid -up car h treat d th pati nt fl r th ir riginal e ar ther [! r life (Bhatia Mead w , 2006 ). p cialized facilitie that help ea e th e pr ce s :fl r m moving on from their pediatric one lo gy team t a primary care etting (A lett et al. 2007). Adult oncologi t-directed £ ll w-up care i another ugge tion made by Bhatia and Meadows (2006) for providing appropriate urveillance f . In thi model , an adult oncologi t coordinate ongoing monitoring and creening for CC (Bhatia & Meadow , 2006). Follow-up care directed olely by a PCP i another trategy for providing LTFU for CCS (Singer et al., 2013 ). In this model , the PCP does not have contact with any specia li sts and instead provides all LTFU for CCS independently (Singer et al. 2013 ). Finally, a bared care model consists of collaboration between a survivor' pediatric onc o logi t and their PCP (Blaauwbroek et al., 2008; Nathan et al., 20 13). The care i mainly provided by the PCP; however, the survivor's pediatri c onco log ist wo ul d provide guidance a needed . These models of care will be addres ed in greater detail in the Discus ion Chapter. 31 L ng- t rm D ll uld b a u eful t p pul ati n and th wh n caring D r th pati nt are a d ru ial t th pati nt -up f pit thi pati nt . crib d ab that pr 1 :G r f thi pati ent P t utili z 111 pnmary car th r ar m an y auier at ari u nt ptimal car [! r tabli hing a D a ibl m d l f care i n bani r a w 11 a ng m g ar in prac ti rporati n of the P clini al practi e, and wi thin th guidelin int prin iple f impl em nt ti n ci nee can im r in detail in th Di fa D a ibl e are m del, the care f m pnmary ca re. ar [! r will b de crib ed hapt r w ill de crib th e lit rature earch pr ce th at wa employed to an wer the qu e tion : h w can for adults who ar e nt the u i n and Rec mmend ati on The following . arg ting th e e e ar [! r pro iding ptimal m pnmar pra ti e. ar for f P be tin hapter . rp orate th e gu id eline int LTF care C ? The purpo e of th e literature ea rch wa to identify oluti ons targeting the banier outlined abo e in thi ecti on utilizing the principl e of impl em entati on science. The information retri eved wa then synthe iz d and analyzed and i pre ented in th e Finding and D iscu ssion Chapters. 32 M ethod The arch trat g mpl d wh n c ndu ting a lit ratur re i w pap r can gr atl i1npa t th numb rand qua lit f a11i 1 that ar retri that th m th ref! r int gral t c ndu t fi cu ed and th r ugh ill be in lud d (Die n u att ili ka, 2 05). ar ing th k B lean phra in g u h a "and .. and · r.. an h av a p r ar h n a pa11icular topi c ( re t l. , 2 ar h fl r an int grati e 5). :arti cl that re.G r n : minal article (th :article that th 1 imi a t wh n e pl ring th iti e rch tenn u ed .G r thi lit rature n er urv 1 d f the .G ll applied t my earch t r 1 ant arti rd and including wer : "fi II "' up·'. " I ng t m1 ~ II \\ up". "'p rim ary ar ". "m del ' hildhood cane r urv1 d . It i f are", r ." The inclu i n crit ri a that I mg: guid line h n pr iding e fir t t pre nt an idea); and plored an r c mpared model f care in ol ed in TF . Exclu ion criteria: :article that focu ed on pediatri c car e· :article written in a language other than English; and :those that tudied a specific side effect of cancer or its treatment. Studies that were greater than ten year old were also excluded (Grove, Bum , & Gray, 2013) to ensure that the research reflected the most recent cancer treatments and their conesponding late effects. Additionally the COG guideline were first released in 2003, therefore research evaluating their recommendations and how to apply them to practice would not have existed prior to 2004 ( OG , 2013). A econd literature earch was conducted to identify implementation science article in order to addres way in which NP can be t incorporate the OG guidelines into their care. ince there i no available data p ecificall y 33 relat d t P and the t 1111 that wer u d , m r g n ral ed. ar h mpn f: ··guid lin imp! m ntati n" and " primar ar ." that£ cu er mpl a : Th in lu i n crit ri n £ r thi :articl ar h t rm guid lin d n th implem ntati n f guid lin in g n eral in pri ary car . lu i n rit ria c n i t d f: :m1icle :a1ticl ritt nina languag th t £ cu ther than ngli h : and d n guid lin impl mentati n in a ut care r th r than primary ar . r n t limited t 1 nd earch arti 1e For thi impl mentati n f guid lin foll wmg ear , a re earch regarding the general n t d p nd ent n th ad a nc m ent tion de cribe the pr that I u ed f tr atm ent . The hen ea rching the databa The earch wa initiated b fir t e ploring the ,ochrane re iew tudie that have been re iewed and lect d ba ed n their hi gh quality and trength (Dicenso et al. , 2005). The keyword "childhood cancer ur ivors" A were used re ulting in 44 m1icle . ince they c ntain '' primary ca re" ine of the article retrieved were eliminated a they tudied smoking cessation, and another five becau e they focu ed on exerci e intervention Five were excluded becau e they inve tigated the coping skills of parents or iblings of children experiencing cancer instead of focusing on the assessment and urveillance of adu lt who have survived a pediatric malignancy. This re ulted in a total of 25 research a11icle . A second search was conducted through the Cochrane library, this time using the search terms " pediatric cancer survivors" and eight articles were retri eved, two being eliminated becau e they focused on smoking cessation. nother article was exclud ed because it examined post-traumatic stress syndrome (PT D) in mothers of children who had been 34 di gn d ith an r. r h D 1d r. dt a h r m ining fi ndu t d u ing th t rm "I ng t nn ~II w up" n ern n nt ut nd a limin t lim in t d k)"v\ rd ·· hildh arti l ' n liminal db b au d m king th .D rtilit tr atm nt clud db cau it u ing the Th th [! cu ping trategi d n p diatri are. au it c n rncd n a11icle wa it in c li ga ted r I vant arti e! [! und car . utiliz d in my e nd earch. he k yw rd D "pri mar car ·· liminated a they addre 11 , and c en liminal d ecau nti n , and ncb d n o hran e librar wa al d d. inall , th a ed, r ulting in a t tal [ o hrane databa Thirteen tudie wer n 1 th r arti le ~a arti u [! c r h d. hi re ult d in 22 t1 n ern d nutriti nal int ''guid line implementati n.. 4, and tw n r ur 1 u r it int n nti n u nd an th r fi trat gi fCI d th 1udcd 2 th u d an n r latin g t , nd n th r thr ity, nd nutriti nal nd n ph rdi " hildh thir ed and thi r ulted in 4 7 artie! d p ific treatment utcome in t ad of guideline , and three more were e eluded ince they concern d trategy imp! mentati n m emergency care. A further three tudie were eliminated a the y focu ed on pediatiic care etting , and two article were excluded a they e aluated imaging pra ctice . The remaining 26 article were aved. Med/ine wa the econd databa qu tion. Thi databa it (Dicen wa cho en b cau earched to retri e article n the r earch of the large numb r of journal in lud d et al., 2005). Th k yw rd " p diatric cane r urvi v r ,. were u d. and the ithin 3 a 11an ul t d in 144 rti 1 . hi r pnmar pati nt ar ." r ult d in nin ubli h d in 2 nd th r mammg ight tudi a r h ph ra nm ry " h i Id h d tudi liminal d b au nt r th in fi e arti hich ar re r ntinuit liminat u f p di atri f the ar p ll nt . ight pr lei nd th i u ly a r h furth r G ur [i cu. wa t be ne fin al r ult wa c elud ed thi an r pati nt er add d t th a taba . hi tim , th It [i u d n m king. w r m r th an t n ar it r ti ent ca re... Th i ntinuit) liminat d in ar h r garding th pnm ar b cau e it tudi d th folio hi h wa ith " prim r) health ar mt in cJ \\ ith r nur 111 g r ph) i i n prim r) f i'f, d/111 ~ d d nt r d and this r ~ ult d in I 1 tudi c . \\ ar h. th fir t i lei d 11 rti I , n nr 11 ndu t d thJ ugh th ar h flllih r r fin th tudi 111 111 r nur ing r ph "prim r h lth h n th 11 d nd arch r ultcd d in th Medline [! Ici er. The final earch ithin theM dlin databa e wa initial d by earchin g " I ng t rm up" d ancer urviv r ... Thi "childh earch yi ld ed 10 re ult and the arti cle were flll1her nanow d to nly includ th e publi heel in 2004 r later. found ; one focu ine a11i cle were don ali ary gland tum ur and wa eliminated, and another wa directed to care of pediatric patient and therefore it wa al o e clud d. The remaining e en article were avec! . M edlin e wa th n earched u in g th keyword -- ~ Ilow up" D ··childh o d cancer urviv r " and there ult were limited t article publi heel in 2004 or later. Th r were 15 re ult and two were liminated b cau e th y concen1ed th treatment f genitourinary cancer and another wa exc lud d becau e it [t cu d n pediatri c car Anoth r eli cu d thyroid cancer th rapi and it wa e eluded and finally on a 36 au Jud d it n rn d p ti nt r f tudi t tal num r l car a ith diab t . h r maining 1 arti a then u rm ·'guid lin impl m ntati n"' r turn d J rti th n dult limit ti n lud r appli d, 4 tt amm d p a pat1i ular tr atm nt. hr lud d the .. prim r~ c r j[j r [! und . limin t d Th final dat ba nee urt th arti ed w r ar h d n r lat d t the a nte t a r tri r cancer) or a ac ut care, and tw cifi c guid eline er ar h th er than ngli h. alu at d th C mili mm nd ati n . Th r mammg nd r ngu g r ning prac ti ce arti I "' r utili nl in lud hum n tudi e rti 1 wntt n in tudi n tin lud d a th r rmn g arch p 11aining t guid lin impl m nt ti n. Th th n in th M dlin d t b rti 1 M dlin rt ining t [! un th er than the d. 'flv' HL. Thi databa wa includ d b ca u e of th e larg numb r f publicati n it c ntain regardin g nur ing and h alth care p ci fi ca ll y (Di n o et al., 2005) . keyw rd earch u in g th term "c hildh d ca ncer urv1 r wa c nducted and thi yi eld ed 6 r ult . The earch wa furth er nan w d by c mbining it with A D "primary health care or primar care nur in g r ph y ician primar ca re r continuity of care." i rele ant arti le re r trieved from thi earch and all were a ed to a I AHL folder. The next earch conducted wa al o thr ugh I AHL. "Pedi atri c ca n cr ur 1vo r wa the phra e u ed, and thi earch re ulted in 75 a11i le . Thi wa then combin ed ith AND " primary health care or primar care nur ing r phy ician primary care or continuity of car " and ten article were r tri d. hr were e elud ed b ca u th tudied P Din 37 h had hil r n diagn m th u [! th 11 a fi th CJ d t th furth r tudi pr gr m [! r [! ld d, n \ a an th r b " hildh d liminat db cau it au it limi11 t d r ut th thad n retri e u mg ith a limit in luding nl arti au r un n r ." h r \\ cr thr it d a n er \\ r1 publi h d in 2 r u dt car h re [! u r re u1t ; ne tm nt and an thcr b hildh in g th databa u ed t ndu t d, [! r a t tal f 14 in the 1 AI !L fo u ed n diab t . Th r maining t o arti le The 1 AHL databa e wa al anc rand d. in all ' th h n m d g nit unnary c n er tr attempted within th r lc ant arti I r gcnit unnar d nth r p1 , and n " hildh liminal db ndu te u i11g th t rm [! r n a k al an r t taling in 11 tudi HL dat ba ar h in th "I ng t rm D II \\ up " a 11 r. HL dat ba final retri ith pmg nd u d d ca n er urvt r wa and neith er re ulted in any article . earch D r re ea rch pertaining t guidelin e implementation.·· uideline implementati n" and thi re ulted in 26 article . even of the tudi D "primar are" w r th ke yw rd u d. retrie ed e aluated pecific in ten' ntion and treatment not relating to guideline and fi ve f th article al o failed to addr guideline of any type. The remaining 14 tudie concemed guideline impl mentation and wer aved . Many f the earch re ulted in o erlap, and thi compl te earch wa accompli h d by u ing th h w that an ari u k yword in hau ti and veral databa compr h n ive ea rch f thre re earch databa e r ulted in a total f _ rel . Thi ant arti I 38 p rtaining t thr ar ft r bri f1 r f ar h libr ri tud ing th arti limin t d a it a ,1 rlapp d d n ingl nth tud tm nt , and D ur fc n r tr hi rti th th literatur nd r fin m n t addr m r th r ughl a h ha d a p diatri m li gnan r 1 ant arti I ar h r n t u ed r m tn laau br andi that Hud ing ithcr lat f[i ct w r r m "' d. fter re ti fi d th m lu i n and e clu r ich 1 t al., .... n, 2 a r nin g D r adult mpl eted, 11 n cri teria [! r th fir t tg t 1., 2 12; n dm n t al. , 2 k t al. 2 a ut amm amining th tr atm nt fWilm tum ur, t n rti I ; H ir a than t al. , 20 1 t a!. , 20 1 effin ger et al. 200 · ing r t a!., 2 I ; uh t a!. , 20 1 , W ng t al. , 2 1 ft rth [! r furth r nd ar h addr aluati n. Ten f the ing guid lin e impl em ntati n 7 article were aved arti le r! app d, r ulting in 0 tudi le en f the e were eliminat d a they e pl red empl yed in practi hether r n t guid elin rath r than D cu ing n trategi tudie were excluded a th y inv tigated th ef[i cti left [! r rev iew . were bei ng [! r their impl ementati ne n. furth r 16 of pecifi c guid elin rath r than implementation trategie . After the tudie were read in d tail , tho e that did not d crib implementation trategie and/or tho e that did not apply to primary care were eliminat d. After a more thorou gh re tew three tudi wer found to b m t relevant to ex pl ring guidelin implementation in primary care. Therefore, th lit ratur re iew re ulted in 14 article that would be mo t pertinent when attempting to an wer my r table have been pre ented D llowing thi arch que tion. Tw hapt r that utnmarize the lit rature ear h 39 . h D 11 mg th m t r 1 ant rti ill r [! und in th rib d, and umJn riz th ir finding . d Tabl l tal arti 1 r 2 d f ith arti 2 arti e! art i Uf\' I V r 22 4 an r 5 chrane implem ntation D primary car 6 7 Medline Medline Pediatric cancer un'lvor D primary hea lth care or pnm ary care nur mg or phy ician primary car or c ntinuity of patient care hildhood can r ND arti cl 47 ar1i cle 9 article 11 at1i le pmg 7- m king cc ati n 1-D rtility treatm nt -p di atri care l -nutriti nal int rventi n l -ex r i e interventi n 13-addr d p cifi c treatm ent , n t guid eline - trategy implementati n m em rgency care 3-pediatric care 2-appropriate imaging 1-publi hed in 2003 6 arti le 26 article artic le n ar ld 5 arti 40 tal ld ur an er r 3 111 1-pedwtri arc !-trea tm ent f th r id 7 rti arti articl e ti n ar 41 able 2 and rimar ar f in lu i n crit ri a aft r detail d 10 guid lin impl m ntati n r rn t guid lin ere u d· n t trategic I - pi red p cifi guid lin e ef~ ti , not trategi 20-did n t fulfill inclu i n criteria after d tail d r tew 42 Find in h ar h trat g d t a i tin an in th M th d h pt r r ult d in ti n: h P ring th re an int ar II r dult h h th d ta pr nt d in th arti and d crib guid lin mpar rib t t 1 f 14 arti I rat th ing h pt r anal z and ppli ati n f th ir findin g to II r fR naly i ar h tudi f th arti 1 r tri \ d fr m the earch were in~ nnati e iteratur re Jew . n pap r that Landi r t al. (2 d fr m ar VI ), and n dman t al. 2 )w r lit rature re iew . ratur r ga rdin g their pr p cti e t p1 articl tudi f the literatur . h paper auth red by will b d and th they utilized to retriev the prn ent, benefit and th limitation in w hi h LTF guid eline and th approached. The e author cit d 63 referenc the proce and the rib d in d tail b 1 Landier t al. (2006) e pl red th d the th f th e II r in their tudy; h w f b th h uld be er they did not exp lain article . Landi ret al. (2006) ub tantiated the knowledge deficit on the part of both the patient and the pr vider with re pect to L F C . A tudy conducted in 2004 by effinger, Hud on, and Marina (a cited in Landi ret al., 2006) con is ted of a con eruence ample of 236 phy ician , and in thi que tionnaire wa utilized to a e II r tudy a 6 item the knowledge and com II rt 1 el of phy ician with . The r ults bowed that P P demon trated about 50% le level r garding LTF f knowledg and omfl 11 compar d t adult and pediatri c onco logi t (Landi r t al. , 2006). In Hud on et al. ' 2002 tud (a cited in Landi er et a!., 2006) 272 adu lt w r 43 d and f th u tr tm nt p ti nt an 2% nd r malign n la d th m i u th t th ir pr id r g rding th r id mp ri andi r t 1. , 2 lat f[i ct andi r r appr at ri at t ular auth r c nclud utilize wh n initiating tr t g t impl em nt ). pc ifi all , andi r et al. 2 -up a th indi idualiz d ar and u auth r ad h and the guideline , th iz d th imp rt n r garding indicati n D r D 11 addre rdi lin guid lin that b th th mph re una ar gu id lin n f th r ning aft r n r ning aft r h t radi ti n and r nthra r and 42 % and d th ir ri k f h rt di an andi r t 1. 2 guidelin r hi t ri ugg t educa ting ell a pr v iding du ati n pr gram illanc r quir d [! r tratif ing pati nt ace rding t le I f ri k [! r P P that dditi nall y, th e e h n pr iding L t (Landier et al. 2006) . In addition t conducting re earch, the auth r fr m th Landier et al. (2 006 ) tud y all work in a clinical pediatric oncol gy etting, and a many of them r gularly publi h tudie on LTF id need in th lit rature ea rch re ult , of C . Their clini cal background add relevance to their finding , although more data will till be n eded t olidi fy their re earch. Weakne e of the Landier et al. (2006) re earch include the fact that thi derived from a compilation of other tudie and a H wick et al. (20 11 ) tud y i plain , th re ulting evidence from uch tudie i not a tr ng. Additionally, a d cripti n of the ear h m thod empl yed t find the included tudi wa omitt d (Landi r et al. , 2006) . Nur practiti ners were n t identifi d a P P who w r included in the tud , \ hi h rna limit 44 th a pli abilit f th finding . inall thi rti 1.,2 ugg ti n pr r g ding h n nt d in th P P nng m r ndi r t al. 2 m luti n h lpful in ar h q u ti n. arg ting tr t gt id r , a w II that an b m thi r P pra ti ffer II r n 1mpr v f b th pati nt and pr int tud ' th kn int 1 tr tif mg r h t unpr 'v the in led ge ba c f ri. k, are ugg ti n rp r t1 n [ th guid line . n dman t al. 2 0 r \ ' I \\ d th b rr1 r t nd the c mparc an u n \ hi h the ba ed th ire alu ati n . The 1 ct d th r in lud d (Fri dman tal., 2 ). n dman t al. (2 Kadan-L t1i k tal. that d m n trat d that nl tr atm nt could r ult in f~ cit d a 2 % f 2 tud y c nduct d by er awar that th ir prev i u t lat r in life. In rd r t addre knowledg , Friedman tal. (20 6) ugg t that the edu cation f urv1 incorporation fan ffecti em d 1 f care, are critical itnilar to th pre IOU earch tudi e th y hen pr thi lack [ r , a! ng with th e idin g LT II r tudy the dem n trated lack f kn wl dge on the part f C and the sugge tion for education targeting thi populati n offer in ight into how the guideline may be incorporated into P practice. A there i a lack of pecificity r garding the type of education that may be mo t effl ctive, fut1her inquiry a to p cific olutio n to impr ve LTFU will be required in rder t apply them to pra tic . riedman et al. (2006) al o ompared vari u mod el of care II r the d li e1y f LTF ~ r , and they divid d the e int cancer- entre ba ed mod el and ommunit - 45 a d m del . n m d l ar r- mmunit m f[i r ntr fr mm 1 n dman et 1. mu hl p n n r t nd t 111 h w r, thi m d 1pr mt ind p nd n T m g n raliz d tting ( ri dman that c mbin d £ 11 -up m a an mmunit - dm d 1 mmunit - r g rding anc r; th tt nd th ir a I t iII ricdman et al. (2 ) hat i , th id al m del t b n d 2 r- nt th pati nt rna pr hi t ri h ha an ( - up ~ h p rt guid d [! 11 n mgp t th lf p ut fprim r ar b lini nd lini fin d 1e uld in ntr D r a defin d tim p ri d [! 11 'W d b tr n fer t the ntr ith ng ing guida n ugg ti n fa pe ific m d I pr tting that ma b m t fD ti nt d in thi fr m th can tud h n appl ing th imilar t th Landi r et al. 2 r ntr a need d. he !uti n r ga rding th n guid elin 6) tud , the auth r in th t th L f ri edman et al. (2006) article all w rk clinically with p diatri c nco l gy pati nt a well a regul arl y publi h tudi e in thi fi ld of pra tice, and their acti e r le in thi ar a add inilu nee t their findin g . That aid there areal o orne weakne e in thi tudy. ince thi r earch utili ze data retrieved from exi ting tudie , it r pre ent a low r level of r earch and other findin g are nece ary to trengthen their data (H wicket al., 2011 ). gain, there wa a lack f explicitl y tat d inclu ion and exclu ion criteria with re p ct t cho ing th e includ ed article , and thi may be indicative of election bia . Additionally, both the e article are alm t ten year ld and more recent tudie in thi fie ld have tronger alidity with re p t to my re earch que ti n. Finally thi re earch paper wa funded by th , which al may ha regarding the finding and c nclu i n ( ri dman tal., 2006). De pit th re ulted in a bia limitati n , thi 46 tud pr m id ugge ti n r garding th nng m re i tin an y tematic r ar h m th d f th nt d t\ r pr lu 1 n rit ria w rc tudi d rib d pr pli itl tat ntra t t th lit ratur r \ i nd in lu i n and ar hing th lit r tur in 11 dif~ r nt datab and ar h mpanng lu i n rit ria, G 11 in d in th re c n m n 201 )0 y tern atic r add 1e a retri w by l f th ir p per wa t indep nd nt re ie er , eight paper tr ngth f thi ed mainl y ia qu tudy a indcp nd nt ti nn a1re (H ir et al. , tud H wicket al., 2 11 )0 tudy d mon trated that m t patient and pr multi-di ciplinary model f are, alth ugh no tudi e comparing LTF (Heir et al. , 2013)0 tcmati r c n ide red a tr ngcr I el [ vid nc and thercfi re thi ignifi anc t th r ult of thi The finding of thi f th u 1 ' th ick t al., 2 11 )0 The parti ipant in th e e tudi c were ta (H areal n d ftcr appl ing their inclu 1 n t\ nt Thi r pre nt ample and th data dg f ar [! r m ed b 0 lp t r du h r tri in th tal., 2 1 ; ing r t 1., 2 1 )0H 1r et al. 2 1 ) c nductc I a , aluat r riate ar ti no 1e' fr m m lit ratur n a pr du ati n f lack of relevant re earch al id r prefeJT d a m d I were fi und re ult din the inclu ion ofuncontro ll ed tudie (Heir et al., 2013 )0 The author al o acknowledged that the outcome of clinic ucce were ba ed on provider or patient perception, which ma y or may n t be an accurat evaluation of true clinic ucce (Heir et al. 2013 )0For patient outcome , uch a appropriat ample, pecific mea urem nt crecning recommendati n , ere n t alu atedo Again , NP were n t explicitly id entifi d a b ing includ d in the tudie , wh ich may limit the app lication of th findin g Finally, mu h of th data co ntain d in the retrie 0 d arti I f 47 ti n 1fin ing f hi 1 rg p t ntial D r ia hi h h in ight int th u fu1 inD nnati n r garding m qu e ti n a it g ati nt t m rna b t b a t th man 1imitati n nd th d and ther ' r ult d in 2 a11i b ing [! und , tud , dditi n I r a ndu t d b int pra ti ar hi n d d t mg r t al. (2 1 care ~ r f n 1 ting main! upp 11 and th g a1 f ur dat ba w r ). he literatur earch f de cript iv d t ( ingcr ct a!. , 2 1 ). r e alu at d th r 1 an e f th a11icle ab tra t in an att mpt t ti n bi a ( ing r mod 1 had m r ad antag t a!. , 20 1 . Th finding d m n tratcd that a harcd ca re mpared t a g neral practiti ner ( P)-led m del [ LT ( inger et a!., 2013 ). Thi m d 1 c mbine the ad an tag p diattic on ol gy with th pro for fthi r n languag Tw ind ep ndent r for guid lin t nt id r . Thi fin ing rp rat th mpar tw r a nd pr f acce care t an ex pert in n of care in an en 1r nment that pr m te independence ( inger et a!. 20 13 ). There are evera1 weakne e inher nt in the mg r t a!. (20 13) tudy. Mo t of the article retrieved involved tudie c nducted in the nit d tate , whi ch may limit the generalizability of their re ult du to the difference in health care tructure betw en and the nited Stat univer al a it i in anada ( inger et al., 2013). p cifically, in the United tate health ar i n t anada, and anada p nd nl y 10.4% fit gro d me tic produ t on health care v r u 16% in Am erica (Nati nal Bur au of c nomic Rc ar h, 20 15). Th e differenc may affect th d livery of h alth care rv ice and ultimat ly ma limit th 48 g n r lizati n fr ndu t din th ar h f T and t pr id p t tr ng ing in lud d h n impl In ntr t t th tudi p cti h rt tud hi va lu at the n p d t anthra thi arti 1 aluated, and hich m d 1 P pra ti 1 d • n d, rti 1 w umqu in th at th r ear her appli d a t- f~ hi h r tud ( d h had b f mg r m del mpanng ti v n W ng t 1. , 20 I ). he imul ati n mm ndati n hildh rch ar guid lin . int tru ture. math mati al imulati n t r ithin the d inD nn ti n r ga rding th t ma be b t uited t retr nl tw ,a t 1. 2 1 ). in 11 th , du e t th la k fr g n da. t ther m d 1 ugg t n pli i tl id tat m ar a1. , 2 pr nit lin ng et al. (20 14 u. d a f urr nt r emng ba d n d at c 11 c t d fr m the t d f a databa e f 4 35 children n 197 0 and 19 (W ng t al. , 20 14 ). The ba ed n the urv y in~ rm ati n retri e ed fr m th e math matical mod 1 u d ri k , and imulat d lifetim c t and t tal ri k f h m1 failure were th en ca lculated fo r different creening interval (Wong et al. , 2014) . The findin g from thi tud y rev a led that dec rea mg creening practi ce (compared with tho e ugge ted by the G) could be recomn1end d, which could reduce the fi nancia l cost by 50% without ignificantly compromi ing the h alth ben fit (W ng et al. , 2014 ). F r exampl e, Wong et al. (20 14) found that fl r tho annual chocardiogram thi recomm nd urv ill ance cou ld be afl ly d crea ed to e ery 2-4 year . Patient wh are ri k- tratifi ed to receive cho ardiogram every 2 year b the deer a thi urv ill ance t every 5 y ar , and th fl r whom the re mm nd may 49 2 14 . h math mati al quati h \ d that h a d d m intain d apJ r hi th d r ith th h W ng t al. 2 14 ar t th fr qu n ar rna d gram h ing th fr qu n guid lin h 11 f hildr n ub t [ ubj d t anthra h t (W ng t 1., 2 14 . ar h. ir t, th data it rna n t n clin wa m lud d, n t nl a narr w limitati n a " rth f h art f ilur umulative in id n ril r f1 ct what uJd b harper decrea , th r rna be ub et in h alth b n fit and thi [! r wh t- ffecti ene imulation,andagain, thi maylimittheapplicati n ofth 2014 ). Additi nally, it i m there w uld be a amined. Anoth r limitation fthe W ng et al. (2014) tudy p t1ain determining c t- ft ctivene . Thee timati n of c ng tal., erall a a r ult [deer a ing f p pulati n a n t ciat d a c trap Ia ted fr m the [! und in r ality (W 20 14). ec nd alth ugh th h alth b n fit did n t decrea ere ning fr qu en ntain d within \'id nee 1 illu tr t d b th fa t that an ntir . ith thi r th tudi ne [ th mmendati r th ir LT n fit a t W ng t al., 2 an imp 11 nt n a it i 111 f the h alth lin mm ndati n . ut at half th tud W ng t 1., t the pr ce f were ba ed on a tud ·finding (W ngetal.. ery difficult to inc rp rate variable uch a medication adherence a well a the en itivity and pecifici ty of echocardiogram creening into a imulation therefore the finding from thi tudy may n t refl ect what would be ob rv d in practice (Wong tal. , 2014). Finally, ince ther i a lack of re arch regarding the hem1 failur ri ks of after 20 year , it i difficult t det nnine the alu and n e it of life- long creening practice (W ng et al. 2014 ). 50 pi t it man limitati n , th r ult fr m thi r pr t- [[! [[! ti n fth th a ll1 hi h h th r th ir ti W ng . h finding tud th t P m abl t addr findin g \' ) t- ugge ti n t int th ir pr ti f ugg ting futur r earch ul in t nn n e that uld a i t in an wering m r ar h t tak int c n id r ti n ac t-b nefit anal y i war n thi t p1 th at mmending ere ning, and t b h nr n t in lud uld b u qu ti n. That aid , it i Imp rtant [! r f[i r rd r t 1mpr 111 guid lin tt r in id mu h t pi ' th th y guid lin , nd r, d lth ugh th al u bl aluating th f th fir t a11i 1 nt n tud ar hi gh! fa n additi nal tudi ma b publi hed in th future. D e cripti ve tudi e . The remaining arti cle th at ere [! und ar d cripti tud y d 1gn and th y all utili z d ith r qu e ti nna1re quantitati data. Thre of th for LTF of and thr tudi Ia ifl ed a r urvey t btain D und in th lit rature ea r h addre ed m del alu at d the u e of LTF f care guid line . Michel et a!. (2009) u ed que tionnaire t gather data from 11 2 parti cipant regarding preference for care delivery. They u d one qu e tionnaire pri or to receiving follow -up and then the pa11i cipant rec i ed a econd qu e tionnaire after th ir fo ll ow-up care to complete at home. F ur model of follow -up were d cribed (p tal/teleph nc follow -up, P-led follow up, nur e- led follow -up and con ultant-led [! ll ow-up), and then patient rated which mod 1 they felt wa be t uited to them (Michel et a!. , 2009). The finding from the Mich I et a!. (2009) tudy bowed that 5.7% of pati nt d ir d a di cu ion of late efD ct during their health vi it , and 5 1.7% of rat d con ultant-led 51 car higher than fi 11 pr nt in th In man bia Mi h 1 t al. (2 ir tl tudi f fi I I fi ur iffi r nt typ e fa mpan n h tr ngth -up rat (7 %) an hi gh r t d, thi d t d pati nt parti i ' p r nur -up dmini t r db ph n , [ lik lih arti ipati n hi h luat d hen utilizing the lit ratur findin g t r c mm nd a c rtain fi rm f fi 11 w-up . data lth ugh th re er t d fr m thi tud 11 tr ngth in thi h t th a tuall fe I r n in prac ti hat i trul ur the pati nt may n t ha c mpari H i t me limitati n . h here the n d ire, in tea d f h ar h, a ) nl pati ent recc1 mg c n ultant-led uld ha affected th eir findin g a e p ri en ed th e ther are m d 1 t be abl e t n b t een th m. or they ick t al.. 2 I I ). Mi chel et al. (2 yed. Thi i d finit ly a fa t r th t har d-mod I; how an think the r dg d an imp rtant bia in their r LTF er bi b th re p nd nt rna r 0 ackn tud , ther ffer a fair ampl , patient may indi cat that they w uld n t d ire a er, thi may impl y reO ct th e fa ct that they may n t kn w what that particular model would con i t of r could ffi r to their care, rather than actu all y refl ecting an infmmed preference. Additionally, P were not pecifically includ ed in thi tud y, thereby potentially limiting the applicability to the e pr vid er . Thi tudy may offer a olution a to which cont implementing the LT t may be effe ti e when guideline · how ver, ince only patient wh rec i ed c n ultant-led were includ ed, and NP were excluded, the tru e applicati n of the e finding i unkn wn. 52 laau br .. 1 1an t mpl t db ph ati nt a k t al. (200 m nt. Pati nt ph 1ini n-it m qu mpl t d c mplet d a thr e-it m qu ti nn ir , and th n ati fa ti n f a h gr up ith qu ti nnatr h d th at 00 bared rat 111 c mpl t d th qu r pon bia r u th tud t d ndu t dan ub qu ntl . . I I n a u cd t interpr t th Ia u br k ct al. 2 0 h h r p nded t a!. (2 0, 0 ) had a high r pat1i ipating phy i ian ti n rate minimize th chanc nth mput r, cr ). la u ick et al., 2 11 ). le ted th ir pati nt by election bia , and increa De pit it le h n th an h d n t r tum it (H 200 ) rand ml y ik rt t 1.,2 ti nnaire . Thi hi gh partici cur el that hi! famil ph hi h 92°o f parti ipating pati nt and whi h ti 1ma1r f pati nt and 2°o fph tr ngth in thi rep n wn ti r m d 1 ith a har d ar m d I ( lauu ati fi d qu an btain infi 1m ti n b ut 1 1 rand ml all d t r nalyz wh r tum the u1 ey dditi nall y, hi h fa laauwb r ek t al. uld deer a th e likelih d of the alidity ftheir re ult . trength , there were al o ome limitati n t the Bl aauwbr ek eta!. (2008) tudy. Fir t, a the data i elf-r ported, th ere i a p tential diffi r nee between what i reported and what actually occur in clinical practi ce (H wick t al., 20 11 ). dditi nally, the CS in the Blaauwbroek t al. (2008) tudy had not experienced other care model compare a bared care m del to , imi1ar t the tudy. Thi ncern ra1 d in the Michel t 1. (2009) econd point limit the ability of thi re earch t an wer my que ti n; alth ugh the find ing fr m Blauuwbroek tal. (200 ) did indicat high ati fa ti on with a har d car m del, only pati nt who were b in g car d for in a har d care model w r ur y d. It i 53 rtain un m ntati n f th h th r thi i th m t appr pn 1 , ati fa ti n guid elin aril im 1 1g t al. 2 12 in tituti n a f[i t net rk , a multi -di ntre [! 11 w-up : 11 t d ta 111 ith a har d car m d 1 d n t an m tituti n r ga rding th guid elin u ag nd nta ting th h iplin r n t rk in ig t I. 20 12) . nt d t II r th t guid lin . in-G rma ti n pe1iaining t r pr nt r pa1ii 1p ting in th Pan hich m t in tituti n had b n tr at d, th qu hi h beth r r n t TF pr gr m in pla . he li t f a ur p an c untri are re largely ac ute care, a th y ti nnaire e amm d fflrdt late raJ a pect h ther r n t guid elin e were 1g t l. , 20 12) . f the ail rementi ned facet mpl d. and hi ch m d l were u d ( f car uld pr id e in~ rm ati n p Iiaining t m re arch qu ti n. Th e e re archer II found that a[! llow- up m del that in lud d a multi -di iplinary tea m wa m afor m nti n d in tituti n ; h w for adult ur i or ( r nl y 3 % f re pond er had LTF ig et al. , 201 2) . Th re ult fthi t de ired by th e program in pl ace tud y al o indi ca t d that, although 8% fin titution reported u ing guid e!in . 25% f-G red littl e to n edu ca ti on t late effect or creening ( [ on ig et al. , 20 12) . There are two main trength in the E ig et al. (20 12) tud y. here arch conducted byE ig et al. (2 01 2) retrieved data from a wide geographical range a it panned a ro urope, which would trengthen th applicability fth ir re ult . They al o an lyz d data b region thereby decrea ing the likelihood f findin g from one regi n being inappr pri atel applied to ther countrie ( ig eta!. , 20 12) . 54 her m limitati n t th r ir t a in th th r hi h n inh r nt ITl h ar h i k ( thi af~ uld ha g n rali zabl t £ a ibl lud d in th 1g t al. 2 12 f ~ 11 th r mall -up, guid line u inall , thi r and du t th dif[i r n hi m d finding r garding m d ducati n f ur rt d , 1. , 2011 . t t pa11i ipa ti ng in Pan ar t al. (2 12 . ap r, th d ta i d in thi t ntial bi 1g ndu t d b in h lth ca r untri tud and and th e nduct d in ult may n tb ntin nt . tud i u ful in n tru tur (multi-di guid lin . Th re ar h nng m r iplinar m nduct d b ar h que ti n a it ithin hi h rna impl ment th ig et al. (20 12 r inforce th e finding education of u1 iv r regarding creening practi ce . Thi r pr ent a guid line int LTF Alth ugh the pre iou tlu·ee tudi comparing different mod el f LT f b th id ntifi d th e n ee d~ r th Landi r tal. (2006 and ri dman et al. (2006) a it al utiliz d t inc rporat the de ired and !uti n whi h can b ar . de crib ed ha e orne limitati n regarding care, th ir re ult provid e m in ight into my re earch que tion. Fir t, thi re earch hi ghli ght th e la k of tudi e that comp are multiple model of LTF care for C . Thi indicate a gap in there ea rch regarding the e type of tudie , therefore fUJ1her exploration into comparing LTF care deli ery i n ce ary. Thi. may be condu cted by NP and could give furth r in ight into h w th y may b tt r car S. econd ly, de pite the limitation , b th ig et a!. (20 12) and Blaauwbroek et al. (2008) demon trated high ati faction with eith r a shared care or multi-di model for L for [! r iplinar t am . Thi gives orne evid n e-ba d in ight into the tru ture of are 55 ~ r whi ha P pra ti ul ad pr m rp rat rm r iding in ight r ult fr m Mi h 1 tal. 2 th finding ting 10 th f alu ti n fth u uh tal. (20 14 t a ph tctan (1 ,1 familiarit r fph th ith th f a addre, d by th fin 1 thr tudi e de ripti c tud y de ign wa u ed di tributed u ey t 2 nited u e guid lin and th ph y i 1811 'kn wl dg r c mm ndati n ntain d within th guid elin phy ician wer qu ti ned n ugg th upp rt r al id r int lin u , nd th nd d) a ar h q u ti n. Th alu qu antitati d in th lit b r in th ir r c n ult nt-1 d it ugg t th f th that ar d li h n att mpting t c alu ted b th th e ( uh et al. , 2 14 ). r pe ifi dditi nall y, had [i r th impr v m nt [ F f ( uh et al. , 2014). The findin g fr m uh t al. 20 14) h wed that ni y .4% and 14.9% f phy ician t c rr ctl id ntif the echocardiography r pecti ely. They al guid elin [i r mamm revealed that a i r acce treatment ummane were ugg t d by phy ician a way to impr graph y and t LTF guid eline and e care for There are everal trength of the uh et al. (20 14) tud y. Fir t, a large number of urvey wer completed and returned in the uh tal. (20 14) tudi e , and th re pon wa over 50%. Acceptable re p n rate for urvey in r earch ha e be n defined a anywhere b tween 50-60% (Nulty, 200 ). Th hi gh number of ph y ician decrea e the likelih od of bia and increa e the validity of the re ult . ne of the few studi rate ut eyed dditionall , it wa that te ted the kn wl edge within the guideline , whi h rna gi e a better indicati n a t the prevalen e f guid line u ag . 56 pit th ithin thi tr ngth , th r ar a ~ limit ti n hi h m 2 11 ) . nd , lud din th in th nit d tat 10 h lud ed fr m thi th ar h, th r p t t nd t thi tim th p p th id r ha P a tudi that nl r ur gam th d ta f pra ti . Th r ar appr (H t al. imat I 177, 2 p thi 1 a ignifi ant pr p rti n fp p nmar and appr pri ate. ciati n f ur 2 15). In ra F alu at d th are g1 n by dat pertai ning t ph y i 1an m diffl r n 111 c pe [practi ce, b th b n id ntifi d in th lit ratur a app r pria te ca r g1 cr fl r ear h i c nducted, th findin g fr m ph y ician ne d t be th ref! r until appli d to u tud ( m n an er n tud . n t r f1 ct th r lit tud h ith thi 11. era!! , the uh et a!. 20 14) tud y i p rtin nt t my qu e ti n a it n t nl y m ti gated th of are h r a la k f Ii ll w- up i occuni ng, but it al o examin ed 1an them el e a t h po ibl e t 1mpr e LT n trate a n d Ii r an impro ement in th fa mili arity of P 0 guidelin . trategie targeted to incr a in g the awarene re ult applicable in addr urvey to 2,520 ( 1, 124 re pond ed) phy ician in the familiarity with the guid eline into ing pa11 of my re arch qu e ti on. The e trategies will be fm1her di u ed in th R comm ndati on Nathan et al. (20 13) al o employed qu antitati with the and u e of the gu id eline by P P that are ba ed on the e finding will allow NP t mcorp rate the their practice making the fl r hapter. de cripti e method and mailed nited tate and anada to a guid line . inding d mon trated that onl y 2% of ph i ian er aware f the r c mm end d th yroid , brea t and cardiac ere ning ( a than t al. , 20 I ). h e 57 d th fr qu n m d 1 f car a than r p rt that tr tm nt umman ph n d ir d pr ar t n ultati n 111 hi h ll a ing tr at111 nt umman 1. ,2 than t al. (2 1 ) % fph i ian , and ith a an r-c ntr % [ d ph Th thi r r tud athan et 1. (2 I ndu t db a r lati 1 hi gh ( 0 0 ), had man trength th r b d r . ing the likelih n 0 rat d fr p nd er bia 111 0 dditi n 11 , thi tud p n p nd r \ ere anadian and th nit d tat , ther b br ad ning th applicability f th e r u 1t ( a th n t a 1. , 2 0 1 inall , the re p nd r and the n n-r p nder th lik lih fr 111 phy ician in auth r anal nd [! und n d f bia and incr a th anada ( 7% f ed the dc111 graphi betw n th ignifi cant difference , whi h fUJ1her the alidity f their findin g ( a than t a!., 201 )0 Lirnitati n f the a than et al. (20 13) tudy includ e th p t ntial bia in If- rep rted data, a w 11 a the clu i n f P in the urv y A prev i u ly 111 nti n d, ther i no inf01mation regarding P and the G guid line in th literatur , 0 pertain to phy ician are extrapolated to the e P P 0 findin g that ga in, the finding fr m thi tudy provide u eful infonnation to an wer my re earch que tion, a they id enti fy a need for an increa e in the di tribution of treatment umma1i , an inc rea e in edu cati n on th part of provider , and a de ire for LTFU that involv collaborati noTherefor , thi data pro id guid elin insight a to h w NP can b tter incorporate the pecific ugge tion regarding way to addre Recommendation hapt r. th int their are of re ult will b d cribed in th 58 Final! 2 .fl mal t Ul ffing r t 1. 2 mpl d quantitati 1 r p nd d th ir m nun graph r mng pr ti d t tmin th m tal., 2 0 ). h findin g in thi d h hi tud al f.fl t th tud h r m n aluat pati nt ( m n ag d 25- y ar wh re ning in th pa t tw amm graph r t were 0-5 Yo hi gh r in ith in r a d g ( effing r t 1., 2 i ian, and th frequency f ). h r ar tw mam tr ngth that an b id ntifi d thr ugh th analy i ffing r t al. (20 ) p rfl nned tati ti al analy e (in luding ag , rae , li ing ar a, la t Papani and u ual urc f car ), whi h (2009) tudy wa th fir t larg finding addre ffin g r d m mm graph mm ndati n fr m their ph r mng m rea d nm rd r t fth h mm nd ti n . nding anal z d d m gra hi data t cr mng r cti f h t r di ar , d pit th m th d b ripti d uld in rea nth ir dat t ac f thi tud y. unt .fl r variab l Ia u m ar, cane r kn wledge and p rcep ti n, their alidity. inc th effi ng ret al. cale tud y t eva lu at brca t creening pra ti e in d tail, it a gap in the r earch and ffer in ight into impr vement for creening. A with all tudie that utilize urv y ne f th limitati n of thi article i th po ible bia inh rent in elf-reported data (Hawick et al., 20 11 ). mammography creening in thi dditi nally, the rate tudy may ha e been over e timat d, ince thi c hort of women wa al o inv lved in a longitudinal tudy where they received new letter curr nt cane r creening guid elines ( utlining ffinger et al., 2009) . on idering th e limitati n and the tudy r ult , thi re arch re eal information regarding th preva lcnc of brea t man1mography for iven that the c mplian f with th guid lin ,a ome ugge t d b th r garding mammograph i ub- 59 trat gi timal an b targ t 1mpr f the h it nth t ph 1an r r mm nd ti n ul ha p rt i ning t m mm gr aid , 111 thi tud nl fi r p ifi uid elin e impl m ntati n tudi . hr r th ar h qu guid lin 1m I m ntati n h an1n B n1.hard ffi cti ene a h . hat f th c nu11 nd ati n trat gi , it ha limit d ap li ca ti n t ti n. dt rat th n t al. (2 1 guid lin int prim ary ca re practi ce. c ndu ted a n n-rand mized ntr li ed tri al that e alu at d th e nding qu ti nnaire t phy ical th rapi t f 16 P ampl r pon e w r c mpared t th d fr 111 my literatur nd part f m que ti n, whi ch i ddr f guid lin impl mentati n b (PT ) in p1imary ar . Th ludi c retri c lin e in primary ar . it ratur pertaining t d th imp! m nt ar h addr P r , and it d e n t r garding m r f th man d n ndati n t nu11 in th int rv nti n gr up , wh PT in th c ntrol gr up at ba line and ix m nth later (Bernhard on tal. , 2014 ). Th guid eline that w re e ami ned c n i ted [ recommendati n for PT treatment fo r low back pain, neck pain, and ubacromia l pain (Benhard on et al. , 2014 ). The implementati n intervention wa multi -component and in vo lved the provi ion [ the e PT treatment guideline for low back, neck and ubacromi al pain in b th a print d and electroni c form at, participation in a thr hour eminar and gr up di u ion , pro i ion of a web ite with link , and fin ally c ndu cting t lephone and email remind r rega rding th u e of th guid elines (B ernhard on et al. , 20 14). Th minars involv d both a I arning comp nent and an hour-long di cu i n gr up , and they ere held on nin eparate 60 a 1 n in a thr -m nth ri d n an yw h r fr m mn 2 t att nd (B nhard n tal. 2014) . In t tal fth 277 T a ign d t th int 1 att nd d th du ati n nhard mmar n t al. 2 14 ). Th findin g fr m th unpr ment int 1 nti n gr up ( mp ar d tud ith th th kn th ntr 1 gr up) rep rt d ea i r a ce % fP in th mpar d t 1 % in th c ntr 1 gr up) h r t find th guid lin ; 2 % [ th int 1 nti n gr up c mpar d t 7% f int rventi n gr up h d great r frequ n ontr 1gr up (B nhard P ;h w % f PT in the t the guid elin ; and f guidelin u c mpar d with 4 % [ P n t al. 20 14 ). The fi nding fr m thi in ight int m qu ti n, a to whi h tra t gie may impr by m m de t ntr 1 gr up) r p rt db mg a are fth e gu id lin ; 40% indi at d in th e p rim ental gr up ( th h w d r ult d m n tr ted that ith 44% in th nti n gr up, 1 a ce tud y can giv t th e m m guid elin er, the finding onl y how a mod t impr vern nt. Th Bernhard n et al. (20 14) paper al o contained e may b inherent a the data i raJ limitati on . ir tl y, a bia If- reported, and thi may not nece aril y repre ent what i een in practic (B rnhard on et al. , 20 14 ). That i , om PT may ha ere ponded ba d n what they think the re earch r may have wanted to find in tead of giving a true response. The author al o acknow ledge that pati ent outcome were not eva luated, and only outcomes from the perspective of provider were measured (Bernhard on et al., 20 14 ). Additionally, the data fo r this stud y were collected at ba eline and ix month 1 ter. If the intervention were continued long- tem1 , thi might have affected the find ing by h wing eith r a greater or a decrea ed improv ment in guid eline awarene and u . Fi nall y, becau 61 thi r ar h di n t in rand miz ti n it i diffi ult t di e dir tl attribut d t th ba d n th inte nti n, it ma a ar n r n e t th alu ate P ,n t P tud nl P in thi alth i u [i r practi hat aid , thi mp rati 1 th typ that ar mu h m r c mm n 111 P P r garding LT appl t a dif~ r nt luti n t impr m in ight a t p guid elin the pul ati n regarding dif[i r nt dif£ r nt pr r, in multi -c mpon ent d li y t m uch a em nt dam d P making it i diffi ult t an b g n ralized t tud addr lth ugh thi h th r th r ult may n t 1. 2 14). rnhard it it limitati n an rn th tud y h th r r n t th fin ling [ p ti nt ntra t t n by P n by finding are limited, ince they n m that ar b in g addre ed by rp rating trat gi that imp art guid lin in[i rmati n in a ffering intera ti e di cu i n that are a il y na iga t d, and reminder y t m are all !uti n th at adh r t th principl e of imp! m ntation cienc and c uld b applied t LT fi r Inc ntra t t the B mhard n et al. (20 14) artie! , the tud y by Le ho, Myer , tt, Win low and Brown (2 005 ) did eva lu ate patient utcome after the impl ementatio n of clinical guideline . Thi re earch con i ted of a b fore and after tud y that exa mined 68,000 patient retri e ed from electronic record (Le h et al., 2005) . Th e e re earch r evaluated the effect of implementing a thma , diabetic and moking ce ation guidelin e on patient outcome in primary care (Le ho et al., 2005) . Th e impl ementati n of the clini al guidelin wa estab li hed by lectur and "t I kit " which c ntain ed alg ritl·un and patient du ation material to fa cilitate guideline ad h renee (Le h t a!., 2005) . 62 h r ult em n trat d that after th a thma guid lin impl m ntati n trat gi r du ti n 111 ( h a a 2% d rbati n-r Ia ted m rg n t al. , e ati n gu id elin it , and a 2 mp ti nt du ati n linical guid elin d pr ur m a urem nt 0 re ult d in o impr h et al. , 2 em ent in cr in pati nt du ati n ( c h et al., 2 Le h ia th a impl m nted th r in pati nt du ati n, a % r du ti n in h m gl bin in bl 2% d la mn bulizer tr atm nt , a 65 % aft r th di a a a 1 % in a put int and a 5) . inall y, th nin g fl r t ba c u m king , and a 7% 5) . t al. 2 0 ) min imiz d a bi a in m ea uring utc m e by u ing a c mputerj zed databa e t e alu at th f guideline imp! m entati n, by pati nt ad mini trati n and managem nt p r onn I who re un aware that th data btained fr m th ir r arch m ay ha been di fferent d pendin g n the am unt f tim pa ed ince the impl em entati n of th gu id elin e et al. 2005 ). tud y wa b ing c ndu ted. T hat a id , th e w hich wa never expli citl y tated) (Le ho dditi onally, ther wa no contr 1 gr up in thi guideline wa m and atory aero tud y ince adh er nee to th e e the whole healthcare orga ni zati on that parti cipated (Le ho et al. , 2005 ). Finally, although the e condition are much m ore con1111 on than late effect from previous cancer treatment would be, they are condition fo r which pati ent ou tcom e are much more a il y m easured . For exampl e, it wo uld be very di ffi cult to detetmin if regul ar mal11111ography as recom mend ed by the resulted in earli er detection and le for wom en who ha e recet d ch t radi ati n morbidity of brea t cancer . o alth ugh the e condition are not a compl ex as LT U for , th y offer ea il y m ea ur d patient outcome and they incorporate the principle of imp] m ntatio n ien e. There fore, 111 e 63 h tal. (200 1n and in r mm n ati n [£ r m th r i n m a ur abl th 1r r ult un 1 m nting th ut m d ta nth an th n b appli d t guid lin ( h r ga rding th 1mp rtant f[i tal. , 2 ). 111 an b a hi t th t adh r nc t r ult d th t h ill b furth r di u trat gi 1 ar h pr id u ha u h findin g reported by Pri r, final tudy found from the lit ratur an k nd pati nt p guid er my r ti n. h n and Rec mmendati n hapter . uerin and n tr ng ement in pati nt ut orne an b applied t inc rp ratin g the d in th m lini al guid lin ub tantial impr are rele ant in h !ping t pra ti mpl uch a alg rithm rp rating imple trat gi tud du (20 1 ) int th c re [ it th e limit ti n , th findin g fr m thi r id n f imp! m ntati n ur abl finding th t appl th pnn ipl nmm er- mer (2 0 ) r pre nt the earch that pertain to guid lin imp! mentati n 1n pnmary car . Thirt -three y temati c review c mpri ed of a t tal f 714 indi idu al tudi e were analyz d in thi y t matic re i w (Prior et al., 2 0 ). i e databa e were earched, and the tudie found w re critically apprai ed u ing an evidence-ba d to I known a AM TAR, an 11 item in trument u ed to evaluate the methodology of y t mati c review (Prior et al., 2008). Thi tool ha been d mon trated by the r effective t 1 in thee aluati n of y tematic r arch to be a r li able and 1ew ( hea et al., 2009). Prior et al. (200 ) e aluated an u m thod of deli ery for ed ucati n, all with varying re ult . Th findin g of the literature revi ewed how d that cdu a ti ona! trategi aimed at staff, uch a co ntinuing medica l ed ucati n ( M ), wer found t have conflicting data regarding their ucce (Prior et al., 2008) . m tudi c [! und up to n 0° o 64 1mpr m nt in h i ian kn 1mpr m nt t ffill1lffi lld M h l 1 tur rib tudi [! und m fth er fth M alth ugh thi u ha r diti nal du ati [! und t in fD ti acr all fth r ar h ). M , int ra ti r d t nnin d 10 f th ntra t t rang d in u and ). it rang d fr m 1al nd in r a (Pri r nD r n e and In th r hi ! that rna unpr d int n it t al. , 2 int 1 enti n ( n fll1 ian kn ari d larg 1 (Pri r ft r a M ith thi 0, 0 du u h a w rk h p and practi ca l ti nal Pri r t a!. , 2 Jew be uc e ful, and ). trat gi fr m a l 7°o d lin e t a 3% impr 111 1 ing audit and feedb ac k em nt in guid lin e compli ance, trategy deer a ed by up t 37% Pri r et al. , 200 ). vid ence clearl y dem n trated that a multi -faceted appr ach wa more f[i cti e th an a ingle trategy (up t 60% incr a in complianc to gu id line ); howe r, ther wa n r lati n hip h wn between the numb r of interventi n and their effecti en involving rna (Prior t al. , 200 ). I uti n media and di tribution had inc n lu i e re ult , and th compl ex1ty of guideline wa in er ely related t their compliance (Pri or et aJ. , 200 ). ince the (2013) LTF guid eline are complex and lengthy, ac rding t Prior et al. (2008) thi wo uld decrea e adh renee to the guid eline . lectr nic reminder r garding guid eline u e dem n trated ignificant ucce , impro ing adher nee up to 7 1. % whil e d r a in g up to 30% (Prior et aJ. , 200 ). De pite the informative re ult r veal ed by their data, there were th Pri r et al. (2008) tud y. me limitati on in lth ugh th e review retri e ed by thi re ear h ere e alu at d 65 b tw ind n 2 0 th au th r n t d th t th m th r tri d nt r m lud d, m me ti n bia hi h ma ha a u m d th th 1e a Ila afG t d th uld b imJ act d if thi fth lid r garding whi h tr tegi limitati n , th e r lin int ful a d in th y me f th articl they rib d in th R ga rdl id n t inall , th re t ud r u1t th ir findin g lini th r ar h a n t th ma pr 1 pra ti ti , 111 rd r t 1mpr addr din th i n and R LT a ( n r et al. , 2 t al. (20 ndu t d by b t . p i (j all y, th ar h ma be appli ed t m int 1. , db th auth r (Pri r n ta ). ) fD r n trat gie id entifi ed a rp rating the guid lin . Th e pecific trategic will be furth r £1 r mm ndati n hapt r . ummary of Findin g In ummar , the r earch ha indi ated a lear lack f T al. , 20 12; Fri dman, tal. 2006 ). have attempt d t uidelin e care £1 r ( uch a tho e d vi d by the and the tandardize ere ning practice £1 r thi pati ent p pul ati on; however adherence r main 1 w a d e awarene f the guideline them elve with pati nt, provid er and y tem banier confounding effort to ucce full y impl ment the guidelin 2013 · athan et al. , 201 3; retrieved indicate ig et effinger et al. , 2009 ; ( , 201 3; uh et al. , 20 14) . The data orne discrepancy a to which care model i b t for L TF Studie show d that ither a multi -di ciplinary approach ( for ig et al. , 20 12), c n ultant-1 d (Mich l et al. , 2009) r a bared m del of care (Bl aa uwbroek et al. , 200 ) i mo t appr pri at when providing L T to c mpared in the Di cu i n . Ther for , the hapt r. mod el will be fu1i h r amined and 66 h arti 1 unp ttan dditi n 11 guid line ill di u fi un that ddre fa multi - m ati nt ut th un 1 m ntati n f guid lin nent trat g ( m re fi und t th r b highlighting th ir imp th r rd r t fwth r arch pr i u 1 an lyz d, T fir rnhard IT mpha iz d th n t a!. 20 14· n r, tal. 2 0 ). lat p iti 1 with th impl m ntati n f t al. 2005). Th fi 11 mbin d wi th uppl m ntary r mg hapter arch in 67 Di cu Th r earch d in ight int m r b fir t addr m f ar ar h qu inding ti n. hi ill th n hapt r ha pr hapt r ing th lack [ pati nt and pr ill b addr b di cu ribed in th wn ill furth r di u id r kn mpar d. in 11 , th r d and th utilit id ed th ba i £1 r an u [ th fi nding th re arch finding r garding T [ in c if£1 r nt rdinating th car f an w ring my r earch qu e ti n will d. Lack of Provid r and Pati ent Knowledge Th la k f kn th 1 dge n the part [ pa ti nt and/ r pr id nc a an imp rtant a p t f L TF fi r ider wa identifi ed within th at cun ntl y r qui r impr vern nt. a than t al. (20 I ), Landi r et al. (2 0 ) and uh et al. (20 14) all ugg ted that du cati n trat gi targ ted t P P w uld help impr (2 006), Fri dman t al. (2006) and LT £1 r . imilarl y, Landi er t al. 1g t al. (20 12) mpha ized th imp rtance f pro iding accurate information to ur 1vor rega rding late effect and cr ening practi ce . The fact that everal tudie have i ued imilar r COllli11endati on trengthen the e fi nding . The evidence coll ected by the e author help to focu the an wer to my re earch que tion, in that the educati on of both pati ent and provid er wa LTFU for hown to be integral when improvi ng S. When combined with the evidence pre ented by Le ho t al. (2005) and Prior et al. (2008), further in ight i provid ed as to which pecific education trategie tend t be most effective for guideline implementation. The e pecific sugge tion for education trategies to improve the inc 1-poration of th outlined in th R cotnm ndati on hapter. guid eline into P practi e will be 68 In a diti n t th pr pr id u ati n, th [[! and/ r ti Mod el of i11 a hi h n u1t nt-1 d, har d fwth r [! r 1a pnm r hi! m u their h alth i an r diagn it d m n tra t th n ithin ne LTF anc r t le ir d mp r db I r addr UI i ( m d 1. an [! r w an r g n an r ll - th ir h alth wi th th ir partm nt [! r th tr c m n 1 lO ar md 1 [! und t b m fth 111 th r di ar r lat d t th tr nmar utilize th m are In nc rn gi t, whether rn t , 20 I ). till th r g n y 2 1 ). Th e rdin are tru tured ti red trategy ha b n d ll1 (B g n y, n.d.), th c nte t f d li ery [ thi new pr gram (i .e., the m d I f care) mu t b tak n int c n iderati n, and the ariou di cu din thi pti n D r th e m del f care are ction . A mentioned pr C t in ha b n id ntifi d in th ar an mu1ti -di ip1in ry t am th nt i u ly, urv1 r hip clinic repre ent one m d 1 f LTF are [! r . The e faciliti e c uld be 1 cated at the arne centre at which the patient recei ed th ir cancer treatment , thereby providing continuity and maintaining the relation hip previou ly built between the patient and their pediatri c one 1 gy team ( ri edman et al. , 2006) . multi- di ciplinary approach ha been ugg t d by many re earcher a an ideal model for T , and a survivor hip clinic i one way to provid e this typ of en ir mnent ( dgar care f et al., 20 12; Friedman et al. 2006; Hadd y et al., 2009) . Alth ugh urvivor hip clinics have e eral advantag careD r , th re ar orne p t ntial drawba k . Th m pr viding ong ing pati nt fa iliti ma n t b locat d in an 69 ar a that i n ni nt .D r ( hatia t a uld lik 1 b 1 th p r th re li ing in 1ural and[ill n 1 a tting . mmunica ti n , ire h lini in th anc u dd ar , w uld ha fa ili ti , nd th [[! r limit d re urc a . M any nc 1 g team w ith wh m th y ha e built p artn r hip inger et al. , 20 1 ). h p nmary ca r centr p atient a] [! r their health c n ern wo uld like t m v p a t their r pati nt, and th ey m ay b di incl ined t return t th wher th y had rec i d th ir an ializ d urv i [! r r (K . id ntificati n a a ca n p c ntr mprehen i ar ugu t 1 ,2 ntinu ed ar b th t al., 20 10; t fth uld b limit d rn ace nl I f thi p ati ent p pul ati n a ( a ill a , 200 ). M th t .D 11 m all r p rti n f di ffi ult tim e att nding p ati nt d M ead r tr atm ent (F ri dm an et al. , 2006). r hip cl inic are m re co tl y and 1 arn e centre dditi nall y, u tainabl [! r pati ent in th long-tenn compar d w ith primary car (Bl aa uwbroek et al. 200 ; inger t aJ. , 20 13 ). A tran ition al m odel of car i another fram ework [! r th e LTF of th at ha been m entioned in the re earch. An exa mpl e of one of the e facilitie i 1 cated at t. Jud e· Ho pita! in T enne ee (A lett et al. , 20 07). H ere, once pati ent have b n di charg d fro m pediatric oncology, th ey then pend one t two year in a p cialized tran iti on program call ed " li ving we ll afte r cancer'' (A lett et a l. , 20 07 , p . 17 7) . In thi care m od l, pediatric and adult pecialtie are combined to provid e care fo r the non-oncology primary care , and to ea e their tran iti n into tting (A lett et al. , 2007) . Long-tenn follow- up directed by p ediatric oncologi t m ay seem to be th mo t appropriate care m odel .D r ; however, thi i n either th e m o t c fea ibl e approach (Bl aa uwbroek et al. , 200 8). !though pati ent d t- eff~ ire the ti nor the mo t ntinuity of are 70 pr id d b famili · are g1 r, u h a th ir p di tri ffl ti t uti liz th t al. , 2 · Maed ar iali t t a e p uld n t n 1 gi t ha k t al. , 20 ma d Ia th ir p (Bradw 11, 20 dditi n ll , if hl gi al gr ; Mi h l et al. , 20 ith ut the 1i k d antag clini nc logi t , ). th y ma y [ mpr mi ing th d and di ad antag ntinui t u h a c ntrac pti n r main d in a p di atric n ir runent, thi th and c uld affl t th ir tran iti n int adulth ). d ran iti nal are c uld ffl r thi c ntinuity f care I pm ntal pr gr fth pati ent. f the tran iti nal car m d 1are imil ar t tho f car by a familiar hea lth car team and ea y ac e cia! worker , p ychol gi t and f t P may ea e th di ffi cult tran iti n of int primary car (Bhatia & Mead w 2006; Hadd y t al. , 2009). M ing dir ctl y from recei ing car from a well -kn wn and c ordinated ncol gy team to that provid ed by a general P P may be too diffi cult for orne pati ent , and a tran iti nal facility may be one potential olution. That aid, ince pediatri c oncology centre are much 1 numero u than primary care centre , di tance to tran iti onal care facilitie may pro e di ffi cult fo r ome (A lett et al. , 2007). This model ha been ucce ful in orne centres in the it could be a viable tra tegy for care in nited tate and me loca ti on (A lett et al. , 2007; Bhatia & Meadow , 2006). Adult-one logi t directed care i anoth r trategy for providing LTF thi ca e, for . In S wo uld r ceiv car in an age-appropriate etting from a peciali t who is famili ar with ca ncer diagno k n 111 in tr ating m r c mm n h alth c n m (Bla u br c t- care ( laau br ril appr pn t pr vid r m a nmary n t ha LTF I gi t it dult pati nt D r g n raliz 2 10) . P diatri th n and cancer tr atm nt (Bhati a & Meadows, 2006) . Howe r, 71 apr idcr h i tr ined in adult an er and th rapt lat can er tr atm nt that a pati nt had r Mad ,2 6) . h al M ad 20 lth k t a l. , 20 tw di f[i rent t c d a a child ( hatia gi t n r ga rding th multi -ag nt h n b ing tr at d fl r an r (Bhati a uld n t be th appr pri te pr vid r .D r rn fl r whi h ; M i hel et al. , 20 9) . f h alth pr may reqUire ar hi n require th ider fl r diffl r nt c n 111 , re ur rt IV ee ulting in th p tenti al fl r rdinat d r m r fragm ent d ar . f [i ring LT ithin a bared are m d 1 i an th r trategy fl r pr vi ling car to -up ca re pr UI hildr n r . inall , n adult nc g n ral, n n-1 te-e fe t (Bl aa u br limit d familiarity with th rna n t ha e ad qu at k.n ch m ther p reg1me that m an le ma ha r hip clini id d u ing thi fram ew rk i le and th pr bl m offering car e in th pnmary car c tl y when c mpared t f tra elling t the e peciali z d cl ini c i tting (Bl aauw br lv d by k et al. , 200 ; inger et a!. , 20 13 ). T he p ediatri c oncol gi t w uld pr vide infl nnatio n and ad ice rega rding late effl ct f cancer treatment and proper urveillance procedure to the P P (Bi aauwbr ek et al. , 2008; athan et al. , 201 3 ). Care in thi m od 1 hould al o invo lve provid er wi th nthu ia m and knowl edge regarding LTF of C , and the e profe ional m ay be m edical one logi t , p ediatric oncologist , fa mil y physicians, ra di ati on oncologi t and inten1 al medi cine p eciali t (K . Goddard, p er onal communicati on, A ugu t 18, 20 15). It i e pediatric oncologi ts and radi ation oncologi t are invo lved in the LTF ntia l that bo th car of mce the know ledge of !at effect can inform practi c and give in ight on h w to redu ce the ri k f late effects in the future (K . odd ard , p r onal co mmunica tion , ugu t 1 , 20 15). 72 h ad antage £r b r m pnmar ar 2 p di atii lini f thi ar m d 1 in lud ti gm a f ing th r ffi m g a can ( laau r pati nt k t 1. ,2 m g r t al. , 20 1 ). hi n D ter uld r car m a a ill a t a!. , 201 O· Parke t al. , ffecti ll ab rati n betw en [ pr p th y id r are in fa ur [ thi m del M ad , 20 inger et al. , 20 1 ). T h degre fi n ment f th p d ia tii n gi t and th r p ciali t m ay a! f ri k int which th u1 r ha been trati fi d furth er ar d p nding n th indi idu alizing care ( ing r et al. , 20 1 ). patient, a w 11 a ace ef£ cti in and n rmali zing h alth are 1 gi t , r di ati n nc 1 gi t and Dr (Bhati a h rt r wait t their pe1ii a care gi er who kn w th hi t ry of th e in the nvir nmen t fa primary care fac ility, i an combinati n that ha grea t p t nti al to pr v id e w ith app r pri ate LT F care (Bhati a & M ad w , 2006) . The neo logy p cia1i t wo uld be able to provid e ng in g guidance u ing e idenc -ba ed guid line to en ure that the pati nt i receiving appropriate creening (Fri edm an et a!. , 2006) . D e pite the benefi t of a hared care m odel, th re are a few di adva ntage . ne chall enge of the shared care m odel would be th at the urv ivor m ay feel un fam ili ar with the N P compared to their previou oncology team , and building a th erapeu tic relation hip with a new care provid er might be challenging (Bhati a & M eadow , 2006: contrast to care provided in a L T care centr , caring fo r C inger et al. , 20 13 ). In in a primary care etting w ould decrea e the ease f access to prov ider in oth r di cipline , th reby making qu ick referral or con ultati on mor tim -c n uming ( inger t a!. , 20 1 ). 73 It h uld al b n t d that, alth ugh n m d 1 w uld pra ti ing in th ra ti diatri f P h uld till b famili ar al. 201 ). Thi familiarit enti al a th 1 gi t and th r p eciali t iding guidanc r garding u1 ith th r c mm nd d guid elin ill b the pr e pati nt and it kn 1 dg abJ r gardin g p t ntial lat ef[i ct ( ing r t al. 20 13 ). nt a id ntifi d a b ing imp rtant t n p t nti al T id r b r d b th e th bani r fa d b the r, a m ti na l and trav lling II a the 1 gi ti c and fin an ial c ncem id entifi ed in P and th h althcare y t m it elf. Teleh alth and/or ace in tant on ultati n ith p mod e l, and in tantl y c nn ct pati ent with p uld al rth le , thi m del luti n that targ t m any [ th pre i u ly id ntifi ed barri er bmTi r inc lud e but ar n t limited t th hall ng ( ing r t ider r p n ibl [! r [! 11 w-up of th r pr illanc iali t co uld a i tin fac ilitating th e uc e Th fin al p tential m d 1 fo r follow-up care c t of a har d care iali t a need d. f care directed o lely by a P P ( inger et al. , 201 3 ). Long- term foll ow-up tru ctured in thi way 1 m re cost-effecti ve and u tainabl wh n co mpared to p ecialized follow- up centre ( inger et al. , 201 3 ). Primary care provider are u uall y in clo e proximity to and therefore di ffi cultie with travelling longer distance to care facilitie are greatl y decrea d ( inger et al. , 20 13 ). A N P ha excellent training to facilitate health promoti o n, a thi a pect of care i reflected within the competencie of P in B ( RNB , 20 13a) . Nur e practitioner ar therefore well- uited to encoura ge to attend the recommend ed creening practi es [! r their care. Disadvanta ge include the lack of kn wledge that N P may ha e r garding th e late effects of pedi atri c m alignancie and their treatm ent , a well a a lack f info m1a tio n th at i requir d to de vi e a urviv r hip pl an if th ey are not in co ntact w ith th ur ivo r· pediatri 74 n 1 gi t r th inall d n t ha imi lar t th t ilitat ac t a c mpr h n i e tr atment ummary ( inger tal. , 201 ). har d ca r m d 1, ar dir t d th r di ciplin fin 1 p int i n t n ce ari ly and p ary ( ing r et al. , 20 1 ). Thi n un ed in thi m d 1 c mp r d t the har d car m del be au llab rati n ith cifi all y indi ca ted a will b furth r de rib d below) ing r t al., 20 1 ). In ntra t, in th h r d ca r m del r gul ar c ntact with a p di atric n 1 gi t mpri c part f th er d fini ti n f thi framew rk ( inger et al. , 20 13 ). Th n id ering th ab hared ca r m del i th e m fram w rk fl r LT fl r a c t a p di atri n etting offer d b a P. t appr pri ate a it i c t-effecti e and it c mbine the e p 11i gi t with the a p ct offered by f n rm alizing h alth in a primary car Role of N ur e Practition er in L TFU for E tabli hing a hared car m d l fl r the LTF accordance with th competencie fo r P in B of n d t be ace mpli hed in ( RNB , 20 13a) . ur e practiti ner are required to " u e co nsultati on and co ll aborati on a appropri ate to co nfirm a di agno i , id enti fy a health n d, or e tabli sh/co nfirm treatm ent r c mm end ati on " ( R 8 . 20 13a, p. 13 ). Since collaboration and con ultation are identified a core competencie fo r NP , and the mo t fea ible care m odels involve con ulting or coll aborating, thi establi he optimal care givers with regard to LTF for P a . A previou ly de cribed, the hared care model i the framew rk revealed by re earchers to b mo t appropria t and de irabl for LTFU of S. onsultation, coll aborati on and referral are pre nt in e ery c mp et n outlin d by the RNB (201 a) for NP in B . N ur e practition r are autonomou provider who w rk in co llab rative models ( RNB , 20 1 b) and th r fore the 75 11 b r ti f r ti natur ( R f th har 2 1 b) . ar m d 1 w uld b m rp rat dint th P pe 76 Recomm endation In rd r t 1mpr h 11 ng an g ap that t ward th pati nt, th pr aD rem nti n d diffi ulti tha t £1 11 £1 r UIT ntl tr t gi h mu t b a1m d t th trat gl an b rdanc with th e rdinatin g p ati ent . Man y fth nb impl em nted r initi at d by int gra l t th tabli hm nt and m a int nan e [ pr id d in thi h pt r addr b t in rp rat th ateg rizcd a b ing dir ct d id r , lD C an u m re guid lin ar pr £1 r ugge tion ider ar th er £1 re . Th r c mm ndati n arch qu e ti n, r ga rding th e way in which int th ir lini ca l practi ce in a primary car P an etting . trategie Targetin g Pati ent In th m pl rin g th impr 1 e c mpn m nt fLT th fir t ub luti n directed t ward t of trategie th at w ill be di u ed. Providing b th tr atment umm ari e and urv J or hip plan , along w ith edu ati onal re ource w b ite and phone applicati n Many urvJv r are the topi c that will be ugge ted in thi w revery young at the time o f their initial di agn w ith uch a ecti on. i , and m ay be unabl e to provide accurate infonnation regarding th eir ca ncer and treatm ent when attending future appointment athan et al. , 201 3) . Thi point illu trate th e nee sity of providing trea tm ent ummarie to patient and fa1nilie once patient are di charged from pedi atri c onco logy (Nathan et al. , 201 3). M any re earchers, a well a the (2 0 13) it elf, tre th importance of providi ng the pati nt with tr atment ummari es once th ir onco logy are ha been compl eted (A lett et al. , 2007; M a da et al. , 2010 ; Nathan et al. , 20 1 ; ing r t al. , 20 13 · uh et al. , 2014) . Wid espr ad u e ofthi typ of communicati on t o l wo uld fac ilitate 77 th tran iti n f mpl t d int adult ar by c n i t ntl . Primar centr r th y ar n t being c n i t ntly a than tal. , 201 ). pre i u I di the tim , P · h we u are pr d tr atm nt umman ider are n t b ing i ing uch tr atm nt umman tih r alidating th ne d fl r m r m pr in th fl nn fa hard c p nly 52% f n th part f p diatric cancer iding u h d cum nt ( athan, 2 l ). tr atm nt ummat mplet d and hared ach urvi vor h uld r cei e a f th e ne ary infl rmati n t d t rmin the d fl r yea r after th e Ma da tal. 2 10) . lf a tr atment umm ary ha n t b n pr that th can c nta t th me f th e infl rmati n that w uld therwi ha b du ati n 2014 ). t a i t wi th r trie ing ided, mpl ti n f th rapy P h uld be aware n ontain d within uch a ummary (The oundati n [! r M edi ca l Pra ctic dditionall y, pati nt may adv cate for th em elve and requ e t a ummary from their p diatric nco l gi t after completion f their cancer trea tm ent . Patient who ha ve urvived childho d cancer can be given infl nnati on rega rding the late effect of their di agno i and treatm nt , and the impOiiance f r gular follow-up can b di cu ed with them (Maeda t aJ. , 20 10). A treatment ummary can be given to patient in both a written and an electronic format. CS c uld even downlo ad their treatm nt ummatie to their cellular telephones o they are abl e to ea il y acce Advocating for patients regarding acce to health care, therapeutic intervention and the healthcare system fonn part of th e competencie for NP i caring for th m any time they are required . P in B ( RNB , 20 13a). If a in th ir practi e, it is their re p n ibility to a i t by advocating for th ese patients and to either cr at or retri eve both treatm ent ummarie and ur iv r hip plan for th e pati ent . hi co uld be compl eted at th e time f acceptance of a ur ivor int 78 th pra ti f th P in a primat· ar fi r ti are fr m w rk uld fa ilitate r tri llab rati n and cl UJ p di atri m ar nta t b t tting. d m n trat d in th lit ratur in a har d car ing tr nt t ( mg r tal. 201 ). tm nt umm an e en th P and th pati nf pedi atri n ,a r b th eir p di atri lett t al. 2007 ; mg r t 1. , 201 ). t fa mili ar w ith an u cane r diagn lth ugh n e id n r hip pl an h uld al t ap pr pria t pro ider t c mp o and th erapi har d inc thi m d 1 mpha ize In additi n t tr atm nt umman nc 1 g1 t i th e m pr viding be pr id ed t th gain, th th e e pl an , m e th y r a tha n et al. 20 J 3 ). m rge regu larl y r garding th frequ ency and type f h uld be und rgoi ng, a urv iv r hip plan w uld prov id e b th th e pati nt and th e P w ith an e p rt-recomrnend d guid lin [! r continu ed cancer urve ill anc ( inger et al. 20 1 · uh t al. ,20 14) . hat ai d, a P w h i th e primarycaregiverfor the LTF of a urv ivor would be re p n ibl e fo r regul arl y upd ating th e survivor hip pl an . Thi way, the patient i recei ing th e m o t up t dat ugge ting urv illance that i creening recomm end ati on and th e P w ill be upp orted by th e late t evidence. uh et al. (20 14) deteJmi n d that providing thi info nnation to relieved their anx iety regard ing their hi tory and ub equent urveill ance, thereby addre ing anoth er barri er to th e eeking of fi llow- up care. T he CO G can also a i t the N P in devi ing a urvivor hip pl an if one wa not pro v id ed by the pat ient' pedi atri c onco log i t (The Fo un da ti on fo r M ed ica l Practice Edu cation, 20 14 ). A list of clinic fo r LTF can be fo und at the http ://www .children oncologygroup . rg/inde /php/ locati ons web ite; pro an con ult w ith and refer to th ese centre fi r a si tance in provi d ing both treatment ummari e a w 11 79 Th undati n b r M dical Pra ti du ati n 2 14). In ad iti n t g1 ing th pati nt b th tr atm nt umman rdinat d tran iti nal ar d um nt dir uld al uld b fa ilitated if the p diatric n tl t th P h pr initiat a dir ct lin tabli hing m r c and urv1 f id ngo mg car fl r n ( uh t al. 2 14 ). d cum nt r n t pr h uld be mad t en ur that a curate and tim ely infl rmati n i gi infi rmati n r garding lat t al. , 20 10; Maeda t a!., 20 10; ffec t hi ided , P h uld I gi t to reque t them ( uh t al. , 20 14 ). Pati nt de ire m r infi m1ati n r garding p tenti all ng-term writing t the pati nt ( a ilia nd the e mmun1 ati n between th tw pr vid r , th r by rdin t d fl ll w-up . If th c nta t th pati nt' p di tri gi t r hip plan , qu elae, and effo11 n b th v rbally and in uh et al. , 20 14 ). me of the an be included in the indiv idual urv1v r hip plan, but it would b u ful forth patient t have ea ier ace to m re detail ed inform ati n h uld they de ire orr quire it. Thi infi rmati n could include what pecifi c late effi ct they ma y experience gi en their individual hi torie , and how oft n creening wo uld be recommended for the elate effect . Providing with ea ily acce ible re ources will a i t them in taking owner hip in their own health care, and in more effecti vely co llaborating wi th their NP when making health care decision . Directing CS to web ites or telephone applicati ns targeting th ir pecia liz d need should be incorporated into both di charge planning from a pediatric oncology fa ility, and upon eeking care in a primary ca r centre ( lett et al. , 2007 ; inger et al., 20 I ; uh et al., 20 14 ). As there i limited follow-up care fi r in B (K. communica tion, Augu t 18, 20 15), web ite uch a the B oddard, p r ona l anc r gency (B ) h uld 80 ha rtin nt infl nnati n [i r ntial b au p tentiallat ha ider that an a il b acce ed . hi i al m r n t fully familiar with the f[i t th p n n e (Ma ti n [i r b th pati nt and pr r garding late ffl ct that (B , 2 1 . It ma r, th y d n t ffl r d tail d in[! rmati n p n nc r the r c mm uld b u ful if thi guidelin mm nd ati n [i r b th pr lat. t al. 2 1 ). urr ntly th B and/ r id r and pati ent , a well a um1na1)' f p t ntial ffe t . h e during and appli ca ti n c uld al it withthe guid lin , th pati nt b it h ha in their practi ( erv a t aching t 1 fl r P P t u e lett t al. 2007) . In additi n to th ir web ite (ww .children one I gygr up . rg) ha man y re urce for a hi t ry of cane r. cone rning late effl ct an ou "h alth link" with pec ifi c inform ati n f each body y t m i ava il abl e on thi ite [i r pati ent u . Bradwell (2009) empha ize the importance of relaying age appr priate informati n to pati ent , and a C become adult , they may de ire more detail ed knowledge regarding their hi tori e and the late effect of th e treatment they received as children. The link located on the C web ite contain detailed and accurate info rmation that wo uld be appropriate for old er patients who desire more information rega rding their care. For example, th health link addressing cardi ova cular ri k factor indicate what life tyle fac tor and tr atment factor (types of radiation and chemotherapy) can increase r deer a the ri k of ca rdia a ul ar effects. The recomm end ed creening to eva lu ate cardiova cular effect i al o a ailab1 on thi s web ite, although it is very general and n t pecific t pre iou ancer trea tm nt . 81 t I ph n a pIi ati n d fr an pr g al and pre pr id th Akr n ith ea il a e ibl e r nti n trat g1 ( kr n hi ldr n' H urc hildr n ' H pita! call d I , tip and in i idualiz d t pita!, 2014 ). anc rLat id r mind r t th pati nt ab ut app intm nt , hat qu e ti n t r m mb r k th ir pr fth ir m di al infi rmati n if th th ir ar ( kr n and ndr id http :// hildr n' 11 canal int t help pati nt id r du ring th ne t i it, and it can e en t r all ne d t r la thi t a P wh d e n t r gularl y pr vid e pi tal, 20 14 . hi appli ati n i a ail abl fl r both iPh ne llul ar t I ph n ; it an al b a e w.canc rl at ef[i ct . rg/ if th e patient d d nlin at n t ha e a cellul ar t leph n . trateoie Targeting Provid er Wh n addr t ward pr mg TF id r . In thi fo r , it i al unp rtant t luti on directed ecti n, educational trategie ri k tratifica ti n, th e length f the guidelin docum ntati n, r earch opportuniti be di cu d. The which the provid r can pecifically impr ve LTF imilar to ffi r and change t in tituti nal p licie wi ll topic will be expl ored within the c ntext of P practice and the way for 111 will be di u ed. , PCP al o require more informati on and upport regarding LTF for patient who have uffered a pedi atric malignancy ( uh et al. , 20 14 ). Ongoing edu cati on for pediatricians and pedi atric oncologi t , a well as for fa mil y phy ician , phy ician a i tan t and NP , i es entia! for providing coordinated L TF Educational ession for tho care for (Fri edm an et al. , 2006). provider who care fo r thi pati ent population w uld ofD r up to date information petiaining t the nece ary ongoing cr ening and pot ntial !at effl t that may experience ( uh et al. , 2014 ). 82 d m n tr t d b Pri r t al. (200 ), pa i nd mmar ar g n rail n t hi ghl efD ti e when attempting t incr a e guideline dh ren int ra ti u h ry thr guid lin h th rk h p c uld in rea f P all cat d within th of and na igating the [! rca e and guidelin e t tud y patient . Thi w uJd u1 eillanc D r th ir patient wh are mpl x and P t of.D r tangibl e ample ab ut f.G ctiv ly in the primary care tting. Tim fl r th educati n p· educational h ur t facilitate r gu lar learning and practice for thi comple pati nt populati n. Increa ed awar ne m-veillan fth ith th guid lin , and gi e th m practice in utilizing th m c uld be pre nt d b ing uch ca tudi e th u p and phy ician caring D r reenmg r c mmendati n t d t rmin th appr priat addr ffered n a r gular ba i (Pri r t al. 2008) uld be a ailab l rking thr ugh ca th familiarit p rtin rk h p helpful in rd r t unpr d t 1min th appr priat 111 uch a 1 tur du ati n trat gi and kill pertaining to the ong ing will promote increa ed diligenc on the part of P in rec rnmending the appropriate creening practice for the e patient . ome re earch r have ugge ted that P Ps tratify their S into three different level of ri k, and then ba e the type of follow-up on the cat gory in which th patient i placed (AAP, 2009 · Bradwell, 2009; Granek et al., 20 12; Landier et al., 2006) . Low ri k patients (or level one) would include th e wh received only urgery or low ri k chemotherapy, and follow-up by a P P by telephone every one to two year would be appropriate (Bradwell, 2009). Level two or intem1ediat ri k patient ar higher ri k chemotherapy, and foll w-up could con i t of appropriat who r ceived creening at a frequency a directed by a P P (Bradw 11, 2009) . Finally, hi gh ri k or le I three pati nt ar 83 h und rw nt M r radiati n an it i r -up b a P P ( rad hi a ). ha liD -1 ng b en a ign d a lev 1 f ri k, th ning h uld b d t rmin d by th e P P u ing th and typ '201 ll 2 1nmend ed th y r c i tratifi ati n i ( g n rdan ith thi initi ati e. imilar t th new ti r guid line r garding T U f tern in , n.d. , and cat g rizing pati nt a cording t ri k an be d n m Ri k tratifi ati n D r rna n t al ay be appli ca bl e. If a P ha nly a [! w in hi /h r pra ti e, ri k tratifica ti n rn a n t b u ful in that parti cul ar cJini al ha great r than fi e H in hi /her pra ti ce, I w uld r c mm nd the at r m nti n d trat gy p rtaining t pati ent tratificati n. Thi pro iding th m tting. oluti on would a i tin t ffi ci nt and appr pri ate car to ace rding t their indi vidu al hi t ri . Th reD r , in a clinic with greater than fi ve , thi w u ld re u It in m re tr amlin d and tim effi ci nt L whil till pro iding the rec mm end ed fr qu ncy f ere mng. A previ u ly de cribed, the length y nature of the 0 the guid eJin ha been cited by OG (20 13 ) it elf a a barri er to it impl ementation into practice. Th e findi ng from Pri or et al. (2008) al o demon trated that increa ing guid eline complexity result in decrea ed compliance. I have devi ed everal algorithm ( ee Appendix III) that are organized by category of chemotherapy treatment and that ummarize the recommend ation of the The e algorithm can be u ed by NP to formulat a survi or hip plan forth ir pati ent who are . With each of the algorithm , there are some ri k fac t r that would increa e th likelih od of late effect occurring; h wever, the e ha e n t b en included in thi pap r in they do not change the frequ ency of creening ( '20 13). 84 ur pra ti ti n r caring £1 r th fi 11 w-up pr ar pr id d t th f that an u pati nt . their d ampl , electr nic r mind r can b tr m r 1nrn nd d at th n (200 ) a hart f a u1 e ciat d 1 hat i , when a P p n th P will be a! 11ed t any creening that h u1d be t i it . tting 1 tr nic r mind r wa d m n trated by Pri r t al. ing the prac ti ce [ P with r p ct t th 1 f ri k and ry 1-2 year at minimum t any qu t £1 r th ignifi anti in r a ing guid lin c mpli ance and it an be r lati vely ea i1y appli ed t tmpr th 1r a e r ning r c mm ndati n ar b th r gularly updated and t d in a tim 1 mann r a di tat d by th guid lin el um ntati n y t m t unpr re ning frequenci , the e patient houJd b a e ed p cifica !J y review th ir ere ning practi c , and t an wer ti n th at the pati nt may ha ma imum tim to di cu guid eline . D pending n their LT regard ing their [! ll ow-up . hi will all ow fi r pl an and w ill re ult in impro d verall care fi r th e e pati nt . A illu trated by the lack of level I and 1 vel II vid ence repre ent d in the guid eline , there i a grea t need for more re earch ex pl ring appropri ate creenin g practice for CC (COG , 201 3; How ick et al. 2011 ). tronger evid ence upporting urveill ance recommendations will fac ilitate their incorporation into the practice ofNP . Increa ed research on the uptake of guidelines will al o be able to identi fy barri er according to as well a evaluate the effectivenes of the 0 recommend ed practice (Bhatia & Meadows, 2006 ). As baniers are specifi cally id ntified, oluti on can be tai l red to addr them, and effective creening can b rec01nmended a d t nnined by th guid eline by NP would b e tr mely u fu l in pecificall y tud ying th e uptake of th id entifying trategies t impr ve LT id n e. R ea rch for within the nte t ofNP pra tic . imi larl , 85 a tud aluating r garding h ur 2 15 . guid lin impl m ntati n mJ nmary ar w uld f[i r t th m pra titi n r in B rp guid lin adh r n fth e her b th d t tmin d practi uld guid lin (I t gu idelin ntribut tand ard (l t al. , 20 12) . T h re ult D 11 th e guid elin urage t fthi c mpari on i then e their pra ti e (Iver et al. , 201 2 ). tay up t date in th eir practi c by learnin g t u e and effecti ely. f audit and fe db ac k c uld a l and h w th m eth d t impr ve aluat d and compar d t apr - c nlffiunt at d ba k t th indi idu a1 in rd er t tmpr uld en arch t al. 20 12; Pri r et a!. , 200 ). It i d fined a apr c fa n indi idu al i trat g ub tantially t th re udit and D db ack i an effecti i nal prac ti Thi P pra ti int ar r quir d t und erg regu lar hart audit ( RN ata btain d during th r garding u !uti n guid lin m re p cifi ca ll y id entify where, when are n t being recommend ed to infonnation could be furth er u d to d by th eir P . Thi i e trategie t improve th adherence f P to urveillance recorm11end ati on . For exampl e, chart audit inD tm ation c uld be utilized to detennine if the 0 gu ideline are being u ed by Ps in the clinical tting, and if , how, when , and which rec mmend ations are b eing incorporated regularl y into practi ce. Chart audit could al o be tudi ed to detetmine outcom e m ea ur , fo r exa mpl e in det nninin g the likelihood of for developing brea t cancer in pati ent who und rgo the recommend ed creening ver us tho e pa tient wh do no t. This typ e of tud y would be a long- term tudy, and would require much coordin ation and a larg valuabl e inD rm ati on regarding how and if th devel pment of late effec t in ample ize. That aid , it \ ould ofD r guid eline ha e a direc t impa t on th 86 aluating th n m1 anal guid lin ren fth t- [[! ti r t re ning and und r- ith th r m emb r r earch h uld al b undertaken t n ure that th -ba ur d and finan ially id en und f data -ba d, appr priat balanc betw ). oll n v r- ting data and f the health care team t id entify pp tiunitie [! r are pati f the c mpetcncie [! r (201 a . c !lab ratin g la king. An re mng an b r a h d ( andi r t al. 20 arch and t R B ar al 1. , 2014 . r c mm ndati n , an llab rating guidelin that ar b th e id n t ( kinn r r fth pra titi ner uld e k ut pp rtuniti e t ith th r clinic and ther profe uld gi e in ight n how t P id ntifi d by the tudy th wh care b r tructur L TF e t p1c by .R ult and inc rp01·ate th f thi guideline into care and would ultimat ly r ult in improved patient outcome . inally, (20 13a) identifi P can initiate change in poli cy for th eir practi ce setting. Th RNB P a lead r who are invol ed in the impJ m entati n of tandard and who influence policy. ur e practitioner should advocate for clear, preci tandard to u e when caring b r C which would incorporate th practice guid elin care of these patients, a well a into the regularly cheduled visit to discu screening practice . Reque ts can be written by NP to the criteria for acces to their PF tool ( into th e appropriate OG a king to broaden th ir , 20 13 ). This would allow P t acce a alu able resource that would further a i t them in devising and updating urvivor hip plan for Within th eir c linical etting, NPs can cr at tool to a i t them with LTF . A policy or t mplate co uld be devi ed by car [! r P t include e entia ! t pic [! r di during th e e vi its uch a pa t cancer hi t ry and tr atment recei u 1n d, cr ening d n in th 87 la t 1-2 Thi r ill n ur that th p trate Ta r tin With th an f t appr pri at unt, it em that th h n caring fl r id d in UI . Ta ing all bar d ar m d 1 rn a be th m nti al in hea lth-car Thi m d I w uld al pr m d 1 , it an be diffi cult t d termine which ne i lik Jy f th r ar h finding int t iabl e [! r L 20 6· inger et al. , 2 1 ). Thi fram ew rk i the m M ad w hi hi -up . y t m Barri er t b th m (Bhatia d by the pati nt. ializ d pati nt ar b ing e n regularly and will d cr a e th ing 1 t t fl 11 lik lih a mm ndati n , and any late ft t n ti nmg r be m tc t-e ff~ cti v y t m that are fin an iall y trained ( inger et al. , 201 3). t appr pri at in B , a th er arc curr ntl y limited care r hip centre , and therefl r th mor D a ible t ad pt (K . [! r dd ard , p r h ared care fram ew rk would be much nal c mmuni cati on, A ugu t 18 20 15). Additi nall y, thi m od I e m to blend the ben fit o f acce t p eciali zed know ledge demon trat d in th e urvivo r hip clini c with the co nveni ence of being located in a primary car c ntre (Blaauw broek et al., 2008; ti r a B · n ew program identifie (B inge r et al. , 201 3 ). trati fying into the vari u ancer Agency, n.d .) can be done by Ps caring for the e pati ent , and depending on whi ch ti er they belong t , their car m ay r m ain with that provid er w ithin a bared ca re model, or they may be referred fo r pecialized :fl llow-up . The shared care model also eem to addre 111 m any f the identifi ed barrier fl r C eeking L TFU care, which should increa e the uptake of urv illanc practice ( al. , 2007 ; Bl aauwbroek et al. , 2008; ing ret al. 20 1 ). De pi te it di ad antag , a har d care mod el directed by a know I dgea ble P P and guid d by pro ider wi th c perti e in oncology including a pedi atri c on logi t and a rad i logy on o logi t wou ld b th m t 88 appr n h n pr p iding mmum ati n, llab rati n nd (Blaauwbr ugu t 1 , 201 inger et al. 201 ). n ult ati n i cit d b th R P ar pr mp m d 1[! r ra ti ti nmg pra ti e and an lat llab rate nd ith c uld b u ly outlin d, me P (201 a) a prui fth uld car a th main pr vid r in ffe t r p rt d by a urvi or, and w uld I gy pe iali t a nece ary. F r e amp! in their pri ma ry car may be un ur cr pr ddard, qu alifi ed t parti ipat in a har ur r k tal. 200 ; K. m , a urvtv r ttin g fi r qu e ti n regarding f r c mm nd ed frequ ency f thi ning a it i d pend nt n many fa t r , uch a age and cumul ati ve do age f anthra clin ( , 20 1 ). T he P co uld th en con ult with a pedi atri c n logi t to det rmin how fr qu ently thi pati ent hould be receivin g ech cardi ogram , and then would ub qu ntl y r lay thi info rmati n to th e patient, either durin g th eir vi it r by teleph ne afterward A oppo edt a fee-for-service fu nding m del, a bl end ed fundin g model th at ba e fundin g on patient complexity for example, is one opti on th at could decrea e the incenti ve to ee m ore pati ent in a hotier time fra me (Frayne, 20 12) . Thi model would all w for longer visit for complex p atient and therefor the practi ce wo uld have an incentiv to all w more time for patients such a CS . A lthough the cos ts and mechani m f thi typ of funding mod el are more comp lex, u ltimately the cost to the ystem would be redu c d a it encourage well-coordin ated referrals and deer a e ho p i tal isi t (Frayne, 20 12) . ur practiti ner working in thi funding model would then b in an id al po ition to offer LTF for 89 ummary of Recomm end ati on In ummary, in rd r t impr id ntifi d bani r i fi r , an appr a h that targ t many f th e an-ant d . ir t, trategie addre ing pati ent ban-ier that tr atm nt umman nd ut ill an pl an ar gt n1 Maeda etal. ,2 01 ; mg r t al. ,20 1 ; uh et a l. ,2014) . lfth re p n ibilit f the r th P t r tri e th m by ith r uh t al. , 20 14; aminati n 20 14 ). Pati nt ca n al o ad umman pr ential ( a illa e arn t gi n unn g tal. , 2 01 0; n, iti th ntac tin g th e pati nt' pediatri und ati n D r M edical Practi ce h ate [! r th em elve by requ e ting treatm ent r hip pl an pri r t di charge by th e ir pedi atri c ncol g i t. W eb it and uch a th e uch a w b ite and t lephone applica ti n id ed to pati nt during their vi it w ith their uch a ancerLate X h uld be P so th at th ey may acce inD nnati on and tool a nece ary to a i t them w ith their LT U care. econdly, pr id er-related chall nge should be addre ed . Thi wo uld includ pro iding relevant information tlu· ugh work hop t N P who are caring fo r C , en unng that they tratify th se pati ent according to level of ri k (if there are fi ve r grea ter their practice), and encouraging the condu ction of re earch and p licy m aking (Bradwell , 2009 ; Pop lack et al. , 20 14; Singer et al. , 201 3; uh et al. , 201 4 ). proc feedback w ill erve to faci litate optimal and coordin ated follow-up for How ick et al. , 2011 ; Ivers et al. , 20 12; Pri o r et al. , 2008; f audi t and ( , 20 1 inger et al. , 20 I ). Additionall y, trategie aimed at faci litatin g guid e line imp lementati n h uld be mcorp rated into th e clinical etting in ord er to impro e th e uptake f th e m 90 r mm ndati n ( targ t db h t aJ. 2 05 · Pri r tal. 200 ). inally, y tem barri r tab1i hing a har d m d 1 f car fram w rk, whi h i b th finan ially 11 a th m d 1m t d ir d by pati nt and pr a t 1. 20 pra ti id r ( lett et al. , 2007; ing r tal. 2 1 ). Fr m m anal n n h uld be m p diatric n wh n aring ,G r nfid nt that th thi p pu1ati n I g guideline ill b great! impr t be entia! t put int luti n ar implem nted, I am an be b tt r inc rp rat d int d. 1aauwbr ek mbined with my I c n id r th ab 111 pnmat und P practice, and T ,G r 91 onclu ion In nclu i n, m f l d m t th r guid lin c mpan t I it lit ratur pen n e a a RN al ng ith reli1ninary r earch r garding ar h qu ti n: h w an are £1 r adult n h and guid lin £1 r LT P a th n ithin three datab e (Th h uld [ databa u ing vari u c mbination f fter a u ing the guid lin in their practice. h ochran Librwy, M d/in ) t a i tin finding arti le t an w r my r earch qu fth rp rat in a primary are practi d t nnin d that ar h d P be tin ti n. I AHL and fter a th r ugh earch arch term , and th n ub quently appl ing in lu i n and e clu i n cri t ria, I r tri e ed 14 rele ant a1iicle petiaining t my r ar h que ti n. Th r ear h finding care for ( ig et al., 20 12; and the N guideline for ha e attempted to of£ r recomm nd ed creening practice for CS, compliance by Friedman, et al. 2006) . LTF h wed a clear lack f L TF dditi nally, although both the PCP with re pect to the e reconunendati n remain I w ( , 201 3; athan et al. , 20 13· effinger tal. , 2009; IG , 20 13 ; Suh et al., 20 14). The tudi es that addre ed the implementation of guideline suggested a multi-component trategy in the clini ca l etting (Bernhards on et al., 2014; Prior, et al. , 2008) . Electronic reminders were al o hown in the literature to be effective when attempting to implement gu ideline into practice (Prior et al., 2008) . After analysis of the variou mod I of delivery for LTF care, it wa detennin d that the mo t appropriate framework in B w uld be the bared care mod I ( ing ret a!., 201 ). Specific recommendati n included tho e targeting pati nt , pro ider and th healthcare y tern a a whole. Tr atment umm ari and u1 ivor hip plan w re id ntified in the literature as c s ntial tool £1 r provider when aring for ( a illa t a!., . . . 010; 92 Ma da t 1. , 2 10· mg r tal. , 2 1 · uh tal. 2014) . Th re[i r th d h uld P , in b :(1 r iding ur eb it u1d al an f:fl r du ati nal t uch a th X t 1 ph n appli a additi na1 re ource . P ery thr e m nth ; uch a w rk h p c uld lnt ra ti rk h uld b in lud tudi -in:fl rc th m t ef:fl cti e ffer d t int th ir pl an f ar :fl r th in th ir pra ti . ay ur rate th impl em ntati n f th of the f th mmendati n by Finall , a ther i limited T ar b t f[i r d b f , u ha guid elines, and P via chart audit . in B , all of the aD r mentioned recommend ation ithin a hared care m del. Thi w uld allow regul ar care from their guid lin pra titi ner could al m·aged t initi ate rc ar h int und r- tudi d t pt e p rtaining t L adh r n um nt to c ntinue to receive P with the added exp rti e that w uld result from co ll aborati on with one logy peciali t . By fo ll wing the abo G guideline into their prac ti ce. Thi will would b able to better incorporate the ultimately re ult in tand ardiz d LTF evident in thi pati ent population. evid nce-ba ed rec mmendation , P for , and improve the Ia k of fo ll ow-up currently 93 Refer nee . 2015 ). Ad1an in w b it . R tri • nf rp ri kr n hi ldr n ' H I d n an o.fpra ti uid lin : w; I m to th A RE ed fr m http ://www .agre tru t. rg/ w mobil app h lp. childh ood can pi ta l. (- 14). h alth . R tri 11 th , d fr m http :// r survi1 ors slay w .akr n hildr n . rg/ m I haring b l g b b6 d2/ ad m f P dia tri 20 9) . ng-tenn [! II w- up car ~ r p di atri c cancer r . P dialric.. I~ ( ), 06- 16 . d i: 10. 1542/ped .200 - 6 11 n can iati n f http ://ww .aa np . rg/all -ab u t- np /np -fact- h America n f P fact sheet. Retrieved fr m ur e Pra titi ner . (20 15) . 1ini ca l t nc l gy. (20 1 ). Th importance offollow-up are. 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R tri ved fr m http ://annal 104 pp endix I Agree II Tool for Guidelin e a h d mam valuation - OG guideline calculat d by u ing th [! ll wmg: re-m1mmum p Topic cope and Purpo e rail bj ecti ( f the 1.Th guid lin i (ar ) p cifi all y d crib d. 4 "lmpl ementati n f th e guid elin are int nd d to increa e qu ality of li fe and decrea e c mplication-r lated hea lthcare co t [! r p di atri c cancer urvi or by providing tandardized and enhanced follow-up car th r ughout the life pan that a) promote healthy life tyle b) prov id e fo r ongoing monitoring of health statu s c) facilitates earl y identification of late effect and d) provid e timely interventions fo r late effect '' ( G, 20 13, p . xx iii ). 2. The clinica l qu estion (s) covered by the guideline i (are) spec ificall y de crib ed. 4 The 0 guideline answer the question a to how often and which type of screening and a ment are recomm end ed for survivor of childh d cancer . 3. he pati ent to w hom the guideli n meant to apply to ar pe ifica ll y de crib ed. 4 105 Topic tr ngly cop e and Purpo e "Th lin e ar m ati D mam c re = 100% 201 ' p . pnm ar iii). Stakehold er Invo lvement 4 . Th guid eline d velopm ent group include individual from all th e relevant prof! ional group . The guid eline were developed by the COG Nur ing Di cipline in collaboration w ith the Late Effect ommittee. Th ey are upd ated by th e 0 ' L TF Gui de lin e Co re ormnittee a well their a ociated Ta k Forces. Multi-disciplinary experts in th fi eld including nur es, phy ician (pediatric oncologi t and oth er sub pecialti e ), patient advoca t , b hav ioural speciali sts, and other healthcare profe ionals co ndu ct d an ex ten ive review of th guid elines ( ,201 3). 4 106 Topic r In volvem ent 5. T h pati nt' i ha be n ught. and pr at Pati nt ad pr mmittee pr Pr id r ar fth nting f th guid lin are 4 Th guid lin ar int nd ed t b u ed b lini ian u ch a ph y ician , P , ph i ian a i tant and nur e in th fi ld f pediatric , on logy, intetnal medicin , gyne 1 gy and family ti c a w 11 a in ub pecialti e , 20 13) . 7. The guideline ha b en piloted among targ t u er . The initial ver ion of the C G guideline wa relea ed in 2003 for a ix month trial p eriod. After thi it wa revi ed ba ed on feedback. It co ntinu s to be revised and upd ated regularly ( G , 2013) . T opi c 4 Domain core = 92% Score ( trongly Agr e 4 3 2 1 tr ngly Disagree) Ri gour of Development 8. Systematic method were u ed to earch for evid ence. The evid ence upon wh ich th 0 guideline are based has b en drawn upon the pa t 20 year of medical literature, w hi h wa com Jiled by 4 107 Topic wa d Ri gour of Developm nt 9. he crit ri a ~ r lecting th e iden i cl arl d rib d . 2 K w rd in lud d " hildh d anc r th rap ", " mpl i ati n " and " late ef[i ct ,.. and th e r c mbined ith ach th rap eutic e p ur . Inclu i n and e lu i n rit ri a ar n t expli citl y tat d ( , 2 0 1 ). 10. The m ethod u d fo r D nnul ating the recomm nd ati on are c l arl y de crib d . 4 The draft fom1ed a de cribed above wa then ubj ected to recommend ati on by exp ert in va riou fields includ in g nur ing, oncology, behavioural cience and pati ent advocacy, and the draft was sub equently m odi fied. T he econd ver ion of the guideline was th en reviewed by 62 multi -di ciplin ary exp erts fo llowed by a fi nal review and coring by a panel of experts ( G 201 3 ). 11 . The h alth benefit , ide effect , and ri k have been c n idered in formul ating the reco mm nd ati on . B th pot ntial benefit and h arm of impl ementin g the guid eline are de crib d. B enefit incl u c ea rli er id ntifi ca ti o n nd int rventi on of lat 4 108 Topic r n f i th fal t i id ntifi d a a king t IT nt t pati ent m ' 2 1 ). Ri our of Development 12. her i an pli cit link betw n the r mm nd ati n and the id nc . 4 f c n n u d tennined by pm1 n f a panel f pert r garding hether there i adequ ate id n fo rth r mm ndati n. Thi i ba d n th xi ting id ence, and grading rang fr m 1-2 8 ( , 20 13). 13 . The guid line ha been ex ternall y r iew d by publicati on. 2 pert prio r to it Guid eline wer reviewed by ommittee a ociated with or appointedb y the G ( 0 ,20 13). 14. A procedure fo r updating the 4 guideline i provided. The Ta k Force continue to monitor and update the guideline and they report to the OG LTFU ore onunittee during each guideline update cycle. A new infonnation becomes available, update are pl anned, as well a at lea t every five years ( ,2 01 3). Domain core = 1°o 109 Topic lari ty and Pr ntation 1 . h re mm ndati n and unambigu u . p uid lin tab! ifi 4 [ d, 1 . Th dif[i r nt pti n [! r mana g m nt f th c nditi n ar 1 arl pr nted . 4 r ach th rap uti ag nt, p c ific hi t ry, a m nt , cr enin g and c un elin 0 ar de rib d , a 11 a c n id rati n for furth er te ting ( 201 ). 17 . K y recomm nd ati on s are ea il y identifiable . 4 A e m ent and creening u gge ti n ar e cl earl y lab elled w ith h eading , alon g with a ociated r ference ( 2013) . 18 . The guid eline i upp orted w ith to 1 for application . omplem entary p ati ent educa ti on tool kn w n a " H ea lth -Link , are ava il abl e . Materi al that acco mp an y the guid eli ne includ e templates fo r ummary fonn , detailed in tru cti n for u e, a radi ati on reference guid e, and a tool to det rmine guid eline applicability to indi v idual pati ents. Th guid eline a lso referenc u ing th e we b to I ''Pa p Ii ~ r are" whi c h i ava ilabl to u er who ar m mb er ( , 20 1 ). 4 Doma in co re 100° o 110 Topic pplicabili ty 1 . The t nti al rganiza ti n al ba1Tier in appl ing th r c mm end ati n ha e be n i cu ed . 4 uth r a kn 1 dg th lack f id en tabli hin g ffi ca y f cr nin g hi h m ay d t r pr id er fr m u ing th guid lin . dditi nally, th 1 ngthy natur f th e d um nt i al di u ed a barri er t lini al u ( h 20. Th e p t nti al c t impli a ti n f appl ing the rec01nme nd ati n ha b en on id r d . 4 Th autho r al ackn ow l dge th at a n th e part of patient lack of in uran m ay pro e to be a bani er to th ir attend an ce f L TF care. th er c t includ e time con traint on the p art f pro ider in ord r to utilize the ,20 13) . gu ideline( 2 1. The guid eline pre ents key review criteri a for m onitoring/audit purpose . 3 The multi -disciplinary ta k force continue to m onitor the literature and inform the L TFU core comn1i ttee f any upd ate during each review cycle (every 5 years) ( 0 , 20 13). Topic Editorial Independence 22. T h e guid e line is edito rially ind ep n dent fro m the funding body. he Nati 4 111 Topic 2 d f int r t f guid lin pm n t ha b n r rd d. Jar d 11 b rati n (20 1). R tri .pdf 4 mam -d fr m http ://app . h .in rhl/agre in trum ntfinal 112 Appendi II gree II Tool for Guideline Evaluation- I N guideline cope and Purpo e I. h e rall bj cti ( ) f th guid lin ar ) p cifi all y d rib ed . 4 2. Th linical qu ti n ( ) c ered by th gu idelin i (ar ) p c ifi all de crib d. 4 "Thi guid lin r c mm nd ati id n ~ r b m an ag m e nt of !at f hildh d ca n r" 2). m ur , 20 1 Th guid lin e an wer th e qu e ti on a t how ft n and which type of sere ning and a m ent are recomm nd d for ur ivor of childhood can cer . 3. The pati ent to w hom th gu id eline i m eant to appl y to are p ecifica ll y de cribed . " [Thi guid eline] i applica ble to everyone w ho has been treated fo r cancer a a child or teen ager, who m ay be at ri k for developing late effect that are largely, but not exclusively, related to the treatm ent they received fo r thei r cancer. Survivor of childhood ca ncer are defin d by age at cane r di agno i and trea tm ent. cro tudi e this va ri e than 24 fr m age le th an 15 t ag I yea r . urv iva l is comm nl y defin ed in tudi a from tw or fi ve o r mor yea r po t trea tm ent" ( I N, 20 L , p. 2).-n p ecifi c age i tat d . 2 113 Topic takeholder Invol vement 1 pment gr up 4 fr mall the I p m n t gr up :D r th e a made up f cardi diatric h mat 1 gi t p diatri n 1 gi t , a p di tri c nd crin 1 g i t, a gcn ral prac titi n r a p diatri cian and a an r urv1 r. ( I 2 1 5. he pati nt' ie ha e b en ought. Lit ratur ofth LTF 3 arch d r gardin g urvi or wa part nt gro up :D r the ,20 13 ). 6. The target u r of th e guideline are clearly defined . ··Thi g uideline i aimed at primary care taff who provide h ealth care for ca ncer urvivor , as well a econdary care and long-term follow-up (late ef:D cts) clinic staff who a e patient and mana ge the long-term care of thi group . Thi guideline will be of relevance to general practitioners and other primary ca re practitioners, p ecialist nur es, oncologi ts, haematol gist , endocrinologi ts, reproductive medicine p eciali ts, cardiologi ts and radiation onco logi t . It will al o be relevant to co un !lor , psycholo gi t , di etitian , phy i th erapi t and denti t a well a to pati ent and their famili " (S I N , 20 1 , p. 2). 4 114 T opic takehold er In vol vement 7 . Th guid lin ha b targ t u r . n pil t d am n g 1 Ther i n m nti n f pil ting th guid line am ng intend ed u r . Th guid lin draft w a r i w d by pert , h r th r i n m nti n [ a tri al ( I 201 Ri gour of D velopm ent . y t m a ti m th d arch fi r id n er u eel t 4 id nc ba ·~ rthi yn th i d in a y t mati c m eth d 1 gy. rev1 w ofth lit rature wa carri ed ut u ing an e plicit arch trategy dev i eel by a I vid ence and In ti nn ati on cienti t. D atabase ea rch d includ M edline, mba e, inahl, P yc iNF and the ochrane Library. Th y ar ran ge cov red w a 2002-2011 . Intern et earch e w ere carri ed out on v ari ou web ite including the ati onal Guid eline 1 aringhouse. The main earch e were uppl em ented by m aterial identifi ed by indiv idual m ember of the development group" ( IG , 201 3, p . 44) . 9 . The criteria for selecting the evidence i clearl y described. D ataba s ea rchecl were 1 rovided, how ever no keyword , or inc1usi n or exclu ion criteria were giv n ( I N, 201 3) . 10. The m ethod u eel for fo rmul ati ng the r c mm end ati on ar clearl y de crib ed . 3 115 Topic Ri gour of D evelopm ent R nt f n in th 11. Th h alth b nefit , id effect , and ri k ha b en con idered in :D rrnulating th r commendati n . 4 "Thi guid line pr id re mmendati n ba ed n CUlT nt evidence for b t practice in identification, a e ment and management of late effe t in urvivor of childhood cane r. dherence to guideline recorrunendati n will not en urea ucce ful outcome in every ca e nor hould they be con trued a including all proper method of care or excluding other acceptable method f care ai1ned at the arne r suits. The ultimate judgement mu t be made by the appropriate healthcare profe ional( ) re pon ible for clinical deci ion regarding a particular clinical procedure or treatment plan ( I N, 2013, p . 2). 12 . There is an xplicit link b tw een the recommendation and the evidence. Recommendation are graded u ing th e radin g f R eco mm endati n , 4 116 Topic tr ngly ment and 2 1 ). Ri gour of D evelopm ent 1 . Th guidelin ha b n t mally r i w db p rt pri r t it publicati n. 4 uid lin re re i wed b Ind p nd nt e ( 201 ). 4 14. pr cedure D r updating th guid line i pro ided . Thi guideline wa publi hed in 2 and will b con id red D r r i w in tlu· e y ar . ny update t the guid line in the int rim p riod will be not d on th I b ite www . ign .ac.uk ( , 2013). Topic Domain c re = 81% trongly Clari ty and Presenta tion 15 . The recommendation are pecific and unambiguou . 3 Recommendation are given after a de cription of nonnal function followed by conunon chemotherapy/radiation effect . Recommendation are organized by body ystem, however recommendation pertaining to pecific chemotherapy dru gs are only prov ided for m ethotrexate and for th cardia c effects of anthracycline . (SI N , 20 13 ). 16. The different option D r mana gement of the conditi ns ar clearl y pre nted. 4 117 Topic larity and Pre entation 17. K rec trun nd ati n ar id ntifi abl . 4 ere nin g ugge ti n mp ani ed b 1 1 f 1 ). 1 . Th guid elin i upp rted with t l [! r appli ca ti n . to 1 for appli ati on f th e guid lin a r ith r r feren ed r rov id ed ( , 201 3 ). Topic Applicability 19. Th p o tential rgani zati o nal bani er in applying th e recormn end ati n have been di scu ed . " Adh ere nce to guid e lin e recomn1end ati ns w ill no t en urea succe ful outcom e in every ca e, no r hould th ey be con tru ed a including all proper m ethod of care or excluding other acceptable m ethods of care aimed at the arne results . T he ultim ate judgement mu t be m ade by th appropriate h ealthcare profe ion al( ) resp on ible for clinical deci ion rega rdin g a p a1iicul a r clinica l procedure o r treatm ent pl an" ( I N, 20 I , p. 2) . The author also acknowledg the lac k of c unent v id ence e tabli shing fficacy f creening ( I N, 20 13). 4 118 T opic Applicabili ty 20. Th p t ntial c t impli ati n f applying th r c nun ndati n ha b n c n id ered. 1 t implicati n [! r guid lin imp! mentati n ar n t addre ed ( I , 201 21. Th guid lin pre nt key r criteria fi r m nit ring/audit purp Th guid line d to con id r in th guidelin ( I T opi c 4 e . me key p int auditing the D mam core = 63% Editorial Ind epend enc e 22. Th guid lin i edit riall y ind pend nt from the funding body. 2 Th rei no mention of who the funding guid lin i (S I body fi r the I 2013). 23 . Conflict of intere t of guideline development has been recorded. 4 Conflict of intere t are declared by the I N executi ve conunittee yearly (SIGN, 20 13). Adapted from "Appraisal of guidelin e D mam core = 50% A RE .pdf ollaboration (200 1). R trieved from http ://app .who . int/rhllagre instrumentfinal 119 ppcndix III lkylating or heavy metals 120 Antimetabolite I j 121 Anthracycline antibiotics j 1 1 1 122 Anti-tumour Antibiotics, Corticosteroids and Enzyme / 123 Plant Alky loid and Epipodophy llotoxin / i I ! + Adapted from "Long-term fo llow-up guide lines for urvivors chi ldhood, adole cent and yo un g adu lt cancer " by th .o rg/pdf/L TF OG (201 ). Retri uid e lin es 40.pdf ed from http ://vvvv\\. urviv r hipguidelin ,