Access barriers mean many patients with cancer ‘not even able to get in the door’
Patients with cancer trying to access care may face obstacles as early as when making their first phone call to a clinic, study findings showed.
Researchers set up simulated patient calls to assess callers’ ability to access a new clinic appointment for three cancer types — colon, lung or thyroid — that disproportionately affect Asian and Hispanic populations.
Trained research personnel assigned to roles of English-, Spanish- or Mandarin-speaking patients called 479 clinic telephone numbers provided by general information personnel at 143 hospitals in 12 states. The simulated callers used standardized scripts to ask about new clinic appointments.
Investigators characterized only 41.5% of calls as successful, defined as callers receiving a clinic appointment date or scheduling information. Results showed a higher success rate among English-speaking callers than Spanish-speaking or Mandarin-speaking callers (P < .001).
“Our study provides actionable insight into the existing barriers that patients may encounter when attempting to access a new clinic appointment for cancer care, and I hope it elevates these barriers to the attention of health care administrators and policy makers who can act to decrease these barriers,” Debbie W. Chen, MD, clinical assistant professor, health services researcher and endocrinologist at University of Michigan, told Healio. “I am hopeful that our study findings will spark more discussion among physicians, patients, health care administrators and policymakers about the need to address these barriers in cancer care delivery on a national level.”
Healio spoke with Chen about the findings, their implications and strategies that may address the care gaps revealed in this study.
Healio: Why did you conduct this study?
Chen: In the United States, there is a well-established association between access to cancer care and improved health outcomes. However, differential access to cancer care services exists in the United States and this contributes to cancer disparities. For patients to successfully access cancer care services, they have to pass through multiple access points, many of which are upstream of the physician visit. For example, prior to a patient seeing a physician, they need to figure out which clinic provides the appropriate cancer care and the telephone number for that clinic. then they have to call the clinic to schedule a new patient appointment and figure out logistics like transportation and time off of work, if applicable, to attend the appointment. An important question that drives my research is which patients am I not seeing in my clinic — not because they don’t want to be there, but because they can’t access the care we’re providing.
Healio: How did you conduct the study?
Chen: This study used an audit survey methodology, also known as a “secret shopper” study. Studies, like ours, that utilize simulated patient callers are not new in the scientific literature, and have the potential to provide system-level data that is both informative and actionable for healthcare policy. All simulated callers followed a standardized script in their respective assigned languages (English, Spanish, or Mandarin). The simulated Spanish- and Mandarin-speaking patient callers started the telephone conversation using two English words — “Speak Spanish?” or “Speak Chinese?” — to assist clinic staff and to simulate a more common clinical scenario. Once the callers were connected to language-concordant staff, they would say the equivalent of, “Hello. I just found out that I have colon/lung/thyroid cancer. Are there any doctors at your clinic who can see me for colon/lung/thyroid cancer? And when is the next available appointment?” The primary outcome was whether the simulated patient caller was able to access care, and this was a binary variable — yes or no. We defined access to cancer care to include the scenario in which the caller was offered a clinic appointment date or provided information on how to schedule a new clinic appointment.
Healio: What did you find?
Chen: First, access to new patient clinic appointments was poor for everyone. The simulated English-speaking patient callers had the highest rate of success, but it was just over 60%, which is not very high. Second, access was worse for the simulated non-English-speaking patient callers. The simulated Spanish-speaking patient callers were able to access cancer care in only 36% of calls, and the simulated Mandarin-speaking patient callers were only successful in 19% of calls.
Healio: What strategies may address this problem?
Chen: We identified two types of barriers. About one-quarter of the 985 total calls ended when simulated patient callers encountered workflow barriers. These barriers included eventually going to a voicemail that didn’t provide the requested information, and being on hold for 30 minutes or more. To address workflow barriers, it is important for each clinic to examine their new patient appointment scheduling workflow and identify potential barriers or gaps in communication. For example, if a clinic has one designated person who handles new patient scheduling, what happens if that person is away from their desk or out of the office? Can another staff member provide scheduling information so that the patient doesn’t have to call multiple times?
We also identified linguistic barriers, which were encountered by almost 50% of the 586 calls made by the simulated Spanish- and Mandarin-speaking patient callers. These barriers included the caller being told “no” or hung up on in response to asking “speak Spanish?” or “speak Chinese?”, and getting disconnected because the automated messages required input but did not provide language-concordant instructions. One potential strategy to address these barriers — though not necessarily easy or applicable to all clinics — is to adjust the telephone workflow so that all callers are connected to a live person every time. For clinics that provide care to a significant population of patients with limited English proficiency, it may be necessary to invest resources to ensure consistent access to and use of professional language interpreters at all points of communication with patients.
Healio: Is there anything else you’d like to mention?
Chen: The majority of patients seeking cancer care will need to contact the clinic to schedule a new clinic appointment. Thus, there is a need for intervention to reduce these communication barriers and optimize the scheduling workflow. Otherwise, this access point will inadvertently function as a gatekeeper to cancer care services and vulnerable patient populations — such as those with limited English proficiency — will be unable to get in the door to see a physician for their cancer care.
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For more information:
Debbie W. Chen, MD, can be reached at chendeb@med.umich.edu.
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