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Originally published as JCO Early Release 10.1200/JCO.2005.05.026 on August 22 2005 © 2005 American Society of Clinical Oncology.
Communication and Coordination: The Keys to QualityDepartment of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY Numerous studies document disparities in cancer care based on race, and many extend this finding to ethnicity and socioeconomic status. Most highlight racial disparities in some aspect of cancer care delivery but fail to specify the mechanisms that lead to this pervasive phenomenon. Although such studies are valuable because they call attention to the magnitude of this problem, without elucidating the specific mechanisms that lead to disparities, they do not suggest interventions to eliminate them. In this issue of the Journal of Clinical Oncology, Ayanian et al1 describe results from a population-based survey of a multiethnic cohort of 1,067 colorectal cancer patients from Northern California. Patients completed surveys modified from the Picker Institute that reveal their perceptions of the quality of their cancer care. The surveys covered the core domains of access to care, symptom control, psychosocial support, health information, treatment specific information, confidence in providers, and coordination of care. Across all racial, ethnic, and linguistic groups, patients perceived access to information, psychosocial support, and care coordination to be the most deficient aspects of their care. African American, Hispanic, and other non–English-speaking patients reported significantly more problems with the quality of their care than white English speakers, and this was especially pronounced in the domains of communication and coordination of care. Despite the wealth of health information readily available in multiple media formats, these surveys reveal that patients desire better communication with their physicians. The study highlights the extent to which patients value having health information filtered, synthesized, and custom-tailored to their individual circumstances by a trusted physician. Communication refers specifically to information flow from physician to patient, and requires that a physician explain the diagnosis, prognosis, and therapeutic options in a comprehensible manner. Communication involves more than a one-way flow of information from physician to patient because it also requires that the physician listen to and incorporate patient preferences into formulation of a final treatment plan. Coordination of care involves facilitating patients' access to the full complement of providers whose expertise may improve their outcomes or experience. It means ensuring that these providers have the necessary information available to formulate recommendations and then function as a team to deliver care. Thus, coordination itself focuses on communication and generally requires that one provider—typically the medical oncologist, but sometimes the surgeon—assume primary responsibility for orchestrating and overseeing all aspects of care. For many cancer patients, this requires more than simply a referral, but rather active engagement by the coordinating physician to ensure that other providers' expertise is indeed obtained and that neither essential information nor the patient him or herself slips through the cracks. The survey by Ayanian et al1 reveals just how highly patients value physicians' roles as coordinators. The eight items adapted from the Picker Institute survey ascertained the extent to which patients knew who was responsible for advising them about specific decisions and how often their providers seemed to be familiar with their problems, had communicated with one another, and had access to all necessary information. These issues of coordination are, of course, especially salient for cancer patients, whose care is typically shared by providers from multiple subspecialties often located at disparate practice sites. Given that colorectal cancer patients customarily undergo evaluation by gastroenterology, surgery, medical oncology, and often radiation oncology departments within the first few weeks of diagnosis, it is not surprising that coordination figures so prominently in a survey about quality of care. The finding that there are deficiencies in colorectal cancer care delivery and that there are racial disparities in perceived quality has been well documented previously by Ayanian and others.2-5 However, what is novel and especially important about this work is that it is one of the first studies to provide us with some specific reasons why African Americans, Hispanics, and non-English speakers perceive their care to be inferior. This enables rational development of quality-improvement initiatives designed to target those aspects of care patients perceived as most problematic. Although there was room for improvement across all domains, communication and coordination appear to be the particular areas that present the greatest opportunity to raise the bar on quality. The study highlights the extent to which language barriers impede the delivery of high-quality cancer care. Across multiple domains, non–English speakers reported more quality problems than nonwhite patients. Whereas 81% of English speakers reported the overall quality of their care as very good or excellent, only 52% of non–English speakers did so. According to census data, 18% of the US population speaks a language other than English at home, and approximately half of these individuals report not speaking English very well. Translation of materials into Spanish and increasing the number of Spanish-speaking health care providers is important since nearly half of non–English speakers speak Spanish. However, because we are a multiethnic multilingual immigrant society, this will not suffice. Telephone companies have increased the availability and decreased the cost of operators who provide translation services in hundreds of languages. These operators can be conferenced into examination rooms to facilitate better communication. Use of translators with training and experience in health care would be even better. Results of the Northern California colorectal cancer patient survey are also significant because of what they do not show—there seemed to be no sign of erosion in cancer patients' trust in their physicians. Across all racial and ethnic subgroups, patients had great confidence in their cancer care providers, perceiving their doctors to be generally knowledgeable, trustworthy, and respectful. Although no item exclusively targeted discrimination, the high degree of confidence that patients expressed in their providers suggests that prejudice is not perceived as a major concern. Cultural competency training for physicians is therefore likely to have less impact on reducing disparities and improving health care quality than re-engineering the cancer care delivery system to better address issues of communication and coordination. Problems that were salient for nonwhite, non-English speakers were similar to those perceived by white English speakers, only to greater degree. Therefore, reducing disparities in cancer treatment requires implementation of quality improvement strategies that should benefit all—prioritization of these efforts should be directed toward care sites where minority and non–English speaking patients predominate. Results of the colorectal cancer patient survey from Northern California have important implications for ongoing efforts to improve cancer care quality. Public and private stakeholders, including federal agencies, provider organizations such as the American Society of Clinical Oncology, insurers, and large employee purchasers, have been working through the National Quality Forum and other groups to create a set of specific measures to evaluate cancer care quality. The goal is to develop a quality of cancer care toolbox that will enable sustainable measurement. Without a defined set of quality measures, it is hard to know where we stand and if interventions achieve their goals. Development of specific quality measures for cancer care has proven to be challenging and labor intensive because it is difficult to identify metrics that have relevance across multiple cancer sites and stages, and cancer treatment recommendations evolve rapidly. This result does not mean that we should abandon efforts to define valid indicators of cancer care quality, but rather emphasizes that even after they are developed and validated—not easy tasks themselves—it will require sustained focus to maintain an up-to-date quality toolbox. For these reasons, patient surveys are an attractive alternative strategy to the development and use of quality indicators to evaluate cancer care. This approach has the advantage of potential applicability to the full spectrum of cancer patients across the continuum of care as opposed to condition-specific metrics with relevance for only a defined subgroup of patients. There is no reason to anticipate that the Picker Institute survey measures used for colorectal cancer patients in California would not also have relevance for evaluating the care provided to lung cancer patients in Florida. The study by Ayanian et al1 suggests that periodic administration of such surveys might be a feasible way to monitor quality of care in oncology practice. Their study did not involve providing physicians with the results of their patients' surveys; however, taking this extra step and providing physicians with feedback about their performance is one strategy to motivate improvement and appeals directly to physicians' professionalism and fundamental desire to satisfy their patients. As health care payers move toward systems that pay providers based on performance, reliance on such surveys to distinguish among providers is likely to increase. The American Board of Internal Medicine has recently started to provide physicians seeking recertification with credits for surveying patients' perceptions of their care and for critically reviewing these results to identify strategies for self-improvement. Development of freely accessible standardized surveys and automated scoring systems could help practitioners to use surveys such as the one used by Ayanian et al1 in their own practices and to use the results to target areas for improvement. Without specific efforts to improve coordination and communication, however, it is unlikely that implementation of large-scale quality of cancer care patient surveys will be sufficient to reduce disparities and improve care. What other strategies might be considered by cancer care professionals? Integrating patient navigators—individuals who share patients' cultural, ethnic, and linguistic backgrounds to help patients negotiate the complexities of the health care system—into the health care team (particularly at sites of care where a high proportion of patients are nonwhite, poor, or non-English speaking) is one remedial strategy designed to optimize communication and coordination. This approach is currently being evaluated in large-scale studies sponsored by the National Cancer Institute, but has the drawback of being expensive because it requires dedicated additional personnel. Without actually hiring a patient navigator, fostering a culture of shared responsibility and teamwork that incorporates the principle of navigation may itself improve coordination of care. Recent efforts to use teamwork models from aviation and other industries to facilitate cooperation by health care teams have met with acceptance by physicians and have exhibited some early successes.6 However, these typically have involved critical care or emergency teams and not multidisciplinary teams of cancer providers who are separated not only across professional roles, but also often across place and time of patient interaction. Another strategy to improve communication is to provide patients with written care plans at the initiation of a treatment course and treatment summaries at the conclusion of an episode of care such as a course of adjuvant treatment. These care plans should describe the diagnosis, the goals of therapy, the specific interventions, the approximate duration, and risks and benefits. Because patients are often overwhelmed by information at the time of diagnosis and often have difficulty assimilating any information during a consultation after receiving bad news, having a written treatment plan that could be referred to later by patients, family members, and potentially other physicians is a logical strategy that just uses good common sense. This is particularly relevant for non-English speakers and poor patients who often have cancer care fragmented across providers or delivered by trainees. Such a document might form the basis for ongoing patient-physician dialogue about therapy. Surgeons have operative notes and radiation oncologists have treatment summaries that succinctly convey what interventions were performed and why. Such a summary document is notably absent from the culture of medical oncology record keeping, and typically medical oncology records contain reams of paper, much of it not useful or able to convey a clear and succinct portrait of the goals and outcomes of cancer treatment. Changing the professional culture of medical oncology to include preparation of these summaries and structuring these documents so that they are meaningful for both patients and other health care providers might simultaneously improve communication and coordination. Patient advocacy groups, such as the National Coalition of Cancer Survivors, have long recommended such a strategy.7 At the end of a chemotherapy treatment course or after a defined interval of several months, treatment plans could be edited to include a synopsis of the outcomes of treatment, how it was tolerated, and intended next steps. In particular, when cancer patients transition from active treatment to surveillance, and then ultimately from close surveillance to long-term survivorship, it would be invaluable for clinicians to generate a summary document that specifies particular concerns and schedules for follow-up evaluations and procedures. These documents could be constructed synoptically and formatted for digital storage, transmission, and coding. Professional organizations such as the American Society of Clinical Oncology, in partnership with patient advocacy organizations, can facilitate this process by developing consensus regarding what key elements these documents should include and ensuring that reimbursement is linked to documentation that is accessible and useful to patients and physicians. Although it is possible that implementing patient surveys with feedback loops to providers and re-engineering the culture of medical record keeping to include patients in the loop might reduce disparities and improve care, sustainable quality improvement is more likely if changes in cancer care delivery are linked to reimbursement. Currently, we are compensated much less for the time spent coordinating care and communicating with patients about their treatments, even though we (and our patients, as the survey by Ayanian et al1 demonstrates so clearly) acknowledge that these may be the most valued services we provide. We are not well rewarded for developing a mutually agreed on post-treatment surveillance schedule after completion of adjuvant therapy, engaging in a lengthy discussion regarding whether or not to administer chemotherapy, or for implementing an end-of-life care plan. In collaboration with major health care payers, particularly the Centers for Medicare and Medicaid Services, we must work to modify the current system for reimbursement to ensure that medical oncologists in particular are compensated for providing essential and highly valued cognitive services rather than for drug delivery. Currently, oncologists expend inordinate amounts of time complying with billing rules that mandate documentation of detailed physical examinations and reviews of systems that no one ever reads, yet we spend far too little time documenting the purpose of treatment or the reasons for changes in therapies and ensuring that this information is clearly transmitted to patients and their other providers. Although altering traditions and entrenched systems requires great effort, the delivery of services that we know are important to patients can be brought into better alignment with the reimbursement system. Changing the professional culture and accepted practices of documentation and aligning incentives to support this effort should promote better communication and coordination. As a result, we might attenuate disparities in care and achieve meaningful improvement in cancer care delivery and the patient experience. Author's Disclosures of Potential Conflicts of Interest The author indicated no potential conflicts of interest. REFERENCES
1. Ayanian JZ, Zaslavsky AM, Guadagnoli E, et al: Patients' perceptions of quality of care for colorectal cancer by race, ethnicity, and language. J Clin Oncol 23:6576-6586, 2005
2. Ayanian JZ, Zaslavsky AM, Fuchs CS, et al: Use of adjuvant chemotherapy and radiation therapy for colorectal cancer in a population-based cohort. J Clin Oncol 21:1293-1300, 2003 3. Ayanian JZ: Race, class, and the quality of medical care. JAMA 271:1207-1208, 1994[CrossRef][Medline]
4. Cooper GS, Yuan Z, Landefeld CS, et al: Surgery for colorectal cancer: Race-related differences in rates and survival among Medicare beneficiaries. Am J Public Health 86:582-586, 1996 5. Ball JK, Elixhauser A: Treatment differences between blacks and whites with colorectal cancer. Med Care 34:970-984, 1996[CrossRef][Medline] 6. Grogan EL, Stiles RA, France DJ, et al: The impact of aviation-based teamwork training on the attitudes of health-care professionals. J Am Coll Surg 199:843-848, 2004[CrossRef][Medline]
7. Stovall EL: Palliative care. N Engl J Med 351:1148-1149, 2004 Related Article
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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