Intervention aims to ‘bridge the gap’ between primary care, oncology
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An intervention designed to keep family practitioners involved in the care of their patients with cancer had a “modest effect” on hospitalizations and ED visits 3 months after implementation, researchers wrote in Annals of Family Medicine.
However, there was no significant reduction in hospitalizations or ED visits after this period, the researchers said. Still, they noted that the findings “provide valuable information regarding potential strategies to consider to bridge the gap between primary care and oncology care.”
“Community‐based family physicians and oncology teams frequently work in silo, and communication/collaboration between them is scarce,” Michèle Aubin, MD, PhD, of the department of family medicine and emergency medicine at the Université Laval in Quebec, Canada, told Healio Primary Care. “It is important to note that this gap is not a local isolated problem; it is well described in the medical literature, too.”
Aubin and colleagues created what she called the “first step to show patients that their family physician is working close to the oncology team, sharing common goals, but having their respective role in their care.” The researchers then tested the intervention during a randomized clinical trial involving 206 patients with lung cancer.
For the intervention, family practitioners (FP) received standardized summaries every 3 months that included information on the prognosis of and treatment plan for each patient enrolled in the intervention group (n = 104). The patients were encouraged to visit their FP within the first 3 months of cancer diagnosis, and a research nurse was available to help coordinate the initial and subsequent appointments to the FP’s office. Oncology teams received patient information that stemmed from these visits, including a list of active problems, other treatments and recommendations from the FP. Patients had “priority access” to FPs, as needed, and these appointments were also scheduled through the research nurse.
Meanwhile, the remaining patients (n = 102) were informed of the trial’s objectives but were not privy to the intervention’s specifics and served as a control group.
All patients’ characteristics were “well-balanced with the exception of patient perception of pattern of care,” according to the researchers. The patients filled out questionnaires at baseline and every 3 months thereafter for 18 months or until they died. The FPs also completed questionnaires, but only at baseline and after their patients stopped participating in the study.
“Our intervention may seem minimalist, but it was important to us that it could be integrated to real practice without too many additional tasks, using the staff in place,” Aubin said.
The researchers reported that there was a perception among FPs (P = .0006) and patients (P < .0001) in the intervention cohort of better interprofessional collaboration compared with those in the control cohort. The patients in the intervention cohort also reported improved “management continuity” (P = .05) and “informational continuity” (P = .001) compared with the control group, while the FPs reported no significant differences in these areas.
Aubin said the “silo” mindset may have prevented greater acceptance of the intervention among FPs.
“There were very limited contacts between family physicians and the oncology team (or the nurse navigator who was identified as the resource person to access the oncology team) besides the exchange of summaries,” she said.
The researchers also reported that there were fewer trips in the intervention group to the ED (24% vs. 36%) and fewer hospitalizations (17% vs. 29%) compared with the control group (P = .05 for each), but this was only observed 3 months into the intervention and not during any other points throughout the study period.
Overall, the researchers said the intervention had no significant effect on health service use and patient distress. However, they encouraged efforts to refine the intervention and evaluate its use in multiple centers.
“It may be frustrating for family physicians to lose their patients with cancer during the treatment phase and to see them back only after a long period of time (months or years after), sometimes to take over to provide palliative/end of life care, without having been kept informed of the evolution of their patients,” Aubin said. “Such interventions may help keep family physicians in the loop ... and improve continuity of care.”
Perspective
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Colleen Conry, MD
Conversations between a patient’s family doctor and oncologist are so important during the crisis of cancer, especially in lung cancer, which is often fatal. There is also a need for continuity around supporting these patients and their families that is really, really important. To me, that is what the study from Aubin and colleagues showed.
Six years ago, I was treated for breast cancer. And throughout my 35-year career, I have been involved in the care of patients with cancer. Therefore, I know from personal and professional experiences that the whole spectrum of cancer care — from tests, diagnosis, treatment and remission — is one of the most important events in the life of a patient with cancer.
Family physicians and primary care physicians can spend time with the patient talking about what the disease means to them, how the disease fits in the context of the rest of their lives, what kind of emotional support might be needed and what should be done to treat other diseases such as hypertension, diabetes and/or the common cold, since these conditions will continue to occur as the patient battles cancer. These clinicians have a relationship with their patients over a long period of time and have the knowledge and training to partner with their patients during these difficult events.
Professor of family medicine and senior vice-chair for quality and clinical affairs, University of Colorado School of Medicine
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Armando Sardi, MD, FACS
The applicability in the real world of the collaboration described by Aubin and colleagues is hindered by an important limitation: these patients had advanced lung cancer and were not candidates for curative treatment. Perhaps a better designed study would be one where patients have longer survival expectations.
No two cancers are alike. In addition, most medical school programs only offer a few months of cancer-related training to future PCPs. That is likely why patients go to radiologists for breast exams, have a dermatologist examine their melanoma, and so on. This gap in training makes communication between a patient’s primary care and the cancer treatment physicians even more critical.
As a cancer treatment physician, when I talk to future and current PCPs, I stress how important it is to screen patients for various diseases, check family history of cancer, and determine the potential risk of the patient or a relative developing cancer. This approach will lead to early diagnosis and more cures. Electronic medical records have made easier the communication of this information between specialties. PCPs can change the lives of many patients simply by asking screening questions like “Did your mother have breast cancer?” or “Did someone in your family have colon cancer?” and so on.
Even when a cancer diagnosis is made, and even when the situation turns terminal, the PCP should still be involved in the care of his or her patient with cancer. For example, many patients with cancer become clinically depressed, and the PCP can either provide treatment or refer the patient to someone who can. In addition, cancer treatments can cause several unwanted side effects such as pain, weight gain, loss of appetite, amongst others. In such instances, PCPs can facilitate ways to limit that weight gain and provide assistance with the improvement of other symptoms. Many children who survive cancer will experience medical conditions and problems later in life that they would not otherwise would have had, and the PCP, not the cancer treatment physician, will be the one diagnosing and recommending treatments for these conditions.
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Douglas Kemme, MD
As an oncologist, I am always asked by my patients at some point in their care if I am keeping their PCP up to date on the progress and setbacks they are making. Therefore, I think PCPs and oncologists should talk to each other about shared patients as often as they can.
This study by Aubin and colleagues was interesting. No. 1, the researchers proved to some extent that these conversations between PCPs and oncologists are helpful. No. 2, the researchers tried to come up with some formalized, defined ways of having these communications. Their approach is a good one. However, it is important to note that while there are some doctors who will dot all the i's and cross all the t’s in their discussions with patients, there are also some physicians who are too busy or simply not interested in formalizing conversations between PCPs and oncologists.
Over the past 3 decades that I have worked in medicine, the way oncologists and PCPs communicate with each other has significantly changed. Conversations in the hallway or lunchroom have often been replaced with a tool within our electronic health record system for which, when an oncologist or PCP enter a medical note about a shared patient, the physician not entering the note is alerted. This tool, when utilized correctly, can also allow for chat windows between these two physicians to discuss clinical matters such as the best treatment for any comorbidities that the shared patient may have. The PCP and oncologist may also want to include those in residency and fellowship in on these discussions, so they can learn more about treating patients with cancer. PCPs within UCHealth have been very appreciative of all these functionalities. Creating this tool will take a little bit of effort, but other health systems and physicians not too keen on the formal conversations might find a tool like this worth implementing.
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