Stakeholder Perspectives on Brain Tumor Care Across Rural-Urban Boundaries: A Reflexive Thematic Analysis

ObjectivesTo explore stakeholder perspectives on care coordination barriers and facilitators in regionalized neuro-oncology delivery, using brain tumors as a model for examining complex care pathways serving mixed rural-urban populations. DesignReflexive thematic analysis of semi-structured interviews from stakeholders across the neuro-oncology care pathway was used to identify themes of care system strengths, systemic barriers to effective service delivery and priorities for system improvement. SettingRegionalized Canadian health system serving one of Ontarios largest catchment areas, characterized by predominantly rural populations and substantial geographic distances to tertiary care. ParticipantsThirty-six stakeholders purposively sampled to represent diverse roles across the care pathway, including family caregivers (n=6), healthcare providers from multiple specialties and care settings (n=28) and Indigenous community advisors (n=2). ResultsTwo main themes with subthemes emerged revealing a tension between localized excellence and systemic fragmentation. Theme 1 (Care System Strengths) included three subthemes: responsive palliative care integration, exceptional provider commitment, and effective intra-institutional communication. Theme 2 (Systemic Barriers to Care Continuity) included four subthemes: absent cross-institutional coordination infrastructure, insufficient pathway standardization, inadequate educational infrastructure for patients and providers and limited regional clinical trial access. Coordination mechanisms functioning effectively within the tertiary center consistently failed at interfaces with referring hospitals and community services, with participants describing patients becoming "lost in transitions." ConclusionsFindings reveal how regionalized cancer systems can achieve localized coordination while failing at system integration. The contrast between internal institutional coherence and external fragmentation suggests that effective care delivery requires deliberately extending coordination mechanisms across organizational boundaries through standardized pathways, shared information systems and defined cross-site accountability structures. Brain tumors, requiring rapid multidisciplinary coordination, expose these interface failures with clarity, offering transferable insights for improving integrated cancer care in regionalized health systems serving geographically dispersed populations. ARTICLE SUMMARYO_ST_ABSStrengths and limitations of this studyC_ST_ABSO_LIPurposive sampling captured diverse stakeholder perspectives across the entire care continuum, from tertiary providers to community services and family caregivers C_LIO_LIReflexive thematic analysis with independent coding by three researchers enhanced interpretive rigor and depth C_LIO_LIBrain tumors function as a model condition for examining care coordination due to their rapid progression and sensitivity to variability in care C_LIO_LISingle health system design limits direct generalizability but enables in-depth examination of coordination mechanisms in a regionalized context C_LIO_LIGeographic and organizational characteristics common to Canadian regionalized systems support transferability of findings C_LIO_LIIndigenous patient perspectives were represented through community advisors; direct patient voices from Indigenous communities would strengthen future work C_LI