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Journal of Clinical Oncology, Vol 26, No 14 (May 10), 2008: pp. 2246-2247 © 2008 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.15.7081
Primary Care Physicians and Oncologists Are Players on the Same TeamCancer Outcomes Research, Cancer Care Nova Scotia, Division of Medical Oncology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada The increasing incidence and prevalence of cancer,1 the growing number and complexity of cancer therapies,2 and the emerging recognition of the unique aspects of cancer survivorship3 are factors that remind us again and again that it takes a health care team to care for patients with cancer. Primary care physicians (PCPs) are crucial to that team,4 and numerous studies have shown that they are keen to be team players for their patients with cancer.5-7 Certainly, the concept of shared care as the key to optimizing the benefits of both primary care and specialist care8 has long been promoted as the way forward for patients with cancer. The shared management approach during active cancer treatment has been studied previously through standardized information transmitted to community-based PCPs with specialist oncology care establishing the treatment protocol.9,10 However, PCPs frequently need a little coaching to help them be most effective when providing care for their patients undergoing active cancer treatments.7,11-13 In this issue, Jefford et al14 report the results of a randomized controlled trial designed to improve the information about chemotherapy regimens that is sent to PCPs with patients on active treatment. The intervention consisted of specifically developed information sheets about the chemotherapy regimen and associated adverse effects. The regimen-specific information sheets were transmitted by fax together with a covering letter, and the primary care practice was telephoned to ensure the fax was received and filed in the patient's chart. This intervention fulfills several of the important principles of effective knowledge translation: the information was tailored to an individual patient, specific to primary care in terms of content and format, and sent in a timely manner to facilitate optimal management of the patient's care.15 Although this intervention was not multifaceted, another important aspect of effective knowledge translation, the design, was elegant and pragmatic, which enhances its generalizability. The strength of the intervention is its relative simplicity. It would appear, however, that calling the practice and ensuring the information was placed on the patient's chart is actually an important component: 17 (39%) of 44 PCPs in the control group reported that they did not receive any information as compared with only three (8%) of 37 PCPs in the intervention group. Even with this extra step, it is difficult to imagine that this simple intervention could not be implemented in most, if not all, cancer treatment facilities. Although a formal economic evaluation was not conducted, the simplicity of the intervention strongly suggests that it would be cost effective. Despite the presumed low cost, however, for an intervention to be cost effective, it must be shown to be effective. In this trial, the outcomes studied were PCPs’ confidence in managing patients receiving chemotherapy, PCPs’ knowledge of indications for referral and chemotherapy adverse effects that their patient might experience, and PCPs’ satisfaction with the information received and with shared care. The intervention was effective in terms of statistical significance for the outcomes of confidence and satisfaction, yet the clinical importance of these improvements is not known. The knowledge outcome did not improve. A substantial concern is that the instruments used to measure these outcomes were not rigorously developed, and therefore one cannot be confident that they are valid measures of the constructs being studied. While the process for developing the intervention was appropriate, the development of the outcome measures did not meet the same standard. Consider, for example, the instrument used to measure satisfaction. The instrument consisted of two items: one item measured satisfaction with shared care, and one item measured satisfaction with communication. The construct of satisfaction is complex and multidimensional, as illustrated by the intricate development processes and multi-item scales used to measure patient satisfaction.16 One suspects that like patient satisfaction, PCP satisfaction is equally multidimensional, requiring more than one item on a two-item scale to measure each dimension. Similarly, as noted by the authors, the failure to detect a difference in knowledge might have been due to the limitations of the measurement instrument. The strong and influential methodology of a randomized controlled trial, rigorously applied as it was in this study, is weakened if the validity of the instruments used to measure outcomes is questionable. The study would have been markedly strengthened if the thorough process used to develop the intervention had similarly been used to develop and test the outcome measures before starting the trial. A matter of further concern is whether these measures—if we accept that they are valid measures of knowledge, confidence, and satisfaction—actually lead to better patient care and, subsequently, improved patient outcomes. Such a relationship is neither apparent nor inevitable. While the outcomes of PCP confidence and satisfaction may or may not be necessary, they are certainly not sufficient to ensure improvements in patient care. A vital next stage of this research, therefore, would be to measure the effectiveness of the intervention on patient outcomes such as symptom management, emergency room visits, unscheduled visits to cancer specialists, and patient satisfaction. Deficiencies in communication between cancer specialists and PCPs is a constant theme in the literature.12,17,18 Methods to improve communication, such as structured consultation letters, have been tested and shown to be effective.18-20 Nevertheless, it is well documented that there remains a wide gap between the information that PCPs need and want and the information they receive from cancer specialists.17 Any mechanism that can consistently narrow that gap would be a valuable contribution to cancer patient care. The study conducted by Jefford et al14 is a useful addition to the literature on the importance of improving and facilitating communication between primary care and oncology care, and increasing PCPs’ confidence in providing individualized cancer care. A promising area of research, which neither this study nor others examining PCPs and their patients with cancer care tested,13,20 include the benefits of electronic communications, such as computerized decision support applications, whereby clinical practice guidelines (CPGs) and reminder systems are integrated into the patient's electronic medical record.21-23 Patient-specific care recommendations derived from computerized CPGs have been shown to increase clinical compliance with CPGs for diabetes mellitus,21 and electronic reminder systems were found to be one of the most important components of a multifaceted intervention to improve preventive care in the general practice setting.24 While there remain problems with these approaches, including low levels of use among PCPs,22,25 the potential is enormous and hopefully will address many of the problems of communication that currently exist. Ever-expanding computer technologies will someday transform medical practice and allow teams of health care professionals to manage individual patient care across settings and distances. Today's "low-tech" solutions, while important and pragmatic, simply cannot provide the same degree of coordination, integration, and information that emerging technologies promise. Patients with cancer are calling for comprehensive coordinated care.1 WHO26 and other organizations27 identify better integration with primary care as a key step. Indeed, shared care models should enable all members of the cancer care team to optimize their performance and deliver the best possible care to patients. Knowledge translation principles, such as the provision of cancer-specific information in formats that are structured for the needs of primary care and delivered in appropriate timeframes to care for particular patients,11 are the ‘coaching’ strategies that can help improve the performance of PCPs. How best to do this has eluded researchers and cancer care systems. Approaches such as those tested in this study, together with the promise of information technologies as mediums for information delivery, are the way forward to solve the knowledge translation challenges that face us in oncology and in all areas of medicine.28 AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest. REFERENCES 1. President's Cancer Panel: Living Beyond Cancer: Finding a New Balance. Bethesda, MD, US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, 2004 2. Systemic Therapy Task Force: Systemic Therapy Task Force Report. Toronto, Canada, Cancer Care Ontario, 2000 3. Committee on Cancer Survivorship: Improving Care and Quality of Life (National Cancer Policy Board): From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC, Institute of Medicine and National Research Council of The National Academies Press, 2005 4. Grunfeld E: Cancer survivorship: A challenge for primary care physicians. Br J Gen Pract 55:741-742, 2005[Medline] 5. Paradiso A, Nitti P, Frezza P, et al: A survey in Puglia: The attitudes and opinions of specialists, general physicians and patients on follow-up practice. Ann Oncol 6:S53–S56, 1995 (suppl 2) 6. Worster A, Bass M, Wood M: Willingness to follow breast cancer: A survey of family physicians. Can Fam Phys 42:263-268, 1996[Medline] 7. Grunfeld E, Mant D, Vessey M, et al: Specialist and general practice views on routine follow-up of breast cancer patients in general practice. Fam Pract 12:60-65, 1995 8. Oeffinger KC, McCabe MS: Models for delivering survivorship care. J Clin Oncol 24:5117-5124, 2006 9. Kisker CT, Fethke CC, Tannour R: Shared management of children with cancer. Arch Pediatr Adolesc Med 151:1008-1013, 1997 10. Wirtschafter D, Carpenter J, Mesel E: A consultant-extender system for breast cancer adjuvant chemotherapy. Ann Intern Med 90:396-401, 1979 11. Zitzelsberger L, Grunfeld E, Graham I: Family physicians’ perspectives on practice guidelines related to cancer control. BMC Fam Pract 5:25, 2004[CrossRef][Medline] 12. Dworkind M, Towers A, Murnaghan D, et al: Communication between family physicians and oncologists: Qualitative results of an exploratory study. Cancer Prev Control 3:137-144, 1999[Medline] 13. Grunfeld E, Levine M, Julian J, et al: Randomized trial of long-term follow-up for early-stage breast cancer: A comparison of family physician versus specialist care. J Clin Oncol 24:848-855, 2006 14. Jefford M, Baravelli C, Dudgeon P, et al: Tailored chemotherapy information faxed to general practitioners improves confidence managing side effects and satisfaction with shared care: Results from a randomized controlled trial. J Clin Oncol 26:2272-2277, 2008 15. Davis D, Evans M, Jadad A, et al: The case for knowledge translation: Shortening the journey from evidence to effect. BMJ 327:33-35, 2003 16. Fitzpatrick R: Surveys of patient satisfaction: II—Designing a questionnaire and conducting a survey. BMJ 302:1129-1132, 1991 17. McConnell D, Butow PN, Tattersall MHN: Improving the letters we write: An exploration of doctor-doctor communication in cancer care. Br J Cancer 80:427-437, 1999[CrossRef][Medline] 18. Braun TC, Hagen NA, Smith C, et al: Oncologists and family physicians: Using a standardized letter to improve communication. Can Fam Physician 49:882-886, 2003 19. Tattersall MHN, Butow PN, Brown JE, et al: Improving doctors’ letters. Med J Aust 177:516-520, 2002[Medline] 20. Nielsen JD, Palshof T, Mainz J, et al: Randomised controlled trial of a shared care programme for newly referred cancer patients: Bridging the gap between general practice and hospital. Qual Saf Health Care 12:263-272, 2003 21. Lobach DF, Hammond WE: Computerized decision support based on a clinical practice guideline improves compliance with care standards. Am J Med 102:89-98, 1997[CrossRef][Medline] 22. Eccles M, McColl E, Steen N, et al: Effect of computerized evidenced based guidelines on management of asthma and angina in adults in primary care: Cluster randomized controlled trial. BMJ 325:941, 2002 23. Jones B, Abidi SSR, Ying W: Using computerized clinical practice guidelines to generate tailored patient education materials. Presented at the 38th Hawaii IEEE International Conference on System Sciences (HICSS-38), Big Island, Hawaii, January 3-6, 2005 24. Baskerville NB, Hogg W, Lemelin J: Process evaluation of a tailored multifaceted approach to changing family physician practice patterns and improving preventative care. J Fam Pract 50:W242–W249, 2001[Medline] 25. Hetlevik I, Holmen J, Krüger O, et al: Implementing clinical guidelines in the treatment of diabetes mellitus in general practice. Evaluation of effort, process, and patient outcome related to implementation of a computer-based decision support system. Int J Technol Assess Health Care 16:210-227, 2000 26. World Health Organization: National Cancer Control Programmes. Policy and Managerial Guidelines (ed 2). Geneva, Switzerland, World Health Organization, 2002 27. Department of Health: The NHS Cancer Plan: A plan for investment, a plan for reform. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4009609 28. Grimshaw J, Thomas R, MacLennan G, et al: Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 8:1-72, 2004[Medline]
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Copyright © 2008 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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