J. M. Young et al.
13 Brook R. (1995). The RAND/UCLA Appropriateness Method. RAND, Santa Monica, CA. 14 Bilimoria K, Bentrem D, Lillemoe K, Talamonti MCK. Assessment of pancreatic cancer care in the United States based on formally developed quality indicators 2009. J Natl Cancer Inst 2009; 101: 848–59. 15 Earle CC. Failing to plan is planning to fail: improving the quality of care with survivorship care plans. J Clin Oncol 2006; 24: 5112–6. 16 King M, Jones L, McCarthy O et al. Development and pilot evaluation of a complex intervention to improve experienced continuity of care in patients with cancer. Br J Cancer 2008; 100: 274–80. 17 Smith SDM, Nicol KM, Devereux J, Cornbleet MA. Encounters with doctors: quantity and quality. Palliat Med 1999; 13: 217–23. 18 Schrag D, Cramer L, Bach PB, Cohen AM, Warren JL, Begg CB. Influence of hospital procedure volume on outcomes following surgery for colon cancer. JAMA 2000; 284: 3028–35. 19 Greenberg CC. Promoting quality surgical care the next steps. JAMA 2013; 309: 827–8. 20 Archampong D, Borowski D, Wille-Jørgensen P, Iversen LH. Workload and surgeon’s specialty for outcome after colorectal cancer surgery. Cochrane Database Syst Rev 2012; 3: CD005391. 21 van Gijn W, Gooiker GA, Wouters MW, Post PN, Tollenaar RA, van de Velde CJ. Volume and outcome in colorectal cancer surgery. Eur J Surg Oncol 2010; 36 (Suppl 1): S55 63. 22 Aubin M, Vezina L, Verreault R et al. Patient, primary care physician and specialist expectations of primary care physician involvement in cancer care. J Gen Intern Med 2012; 27: 8–15.
Cancer care coordination measures
23 Barnes EA, Hanson J, Neumann CM, Nekolaichuk CL, Bruera E. Communication between primary care physicians and radiation oncologists regarding patients with cancer treated with palliative radiotherapy. J Clin Oncol 2000; 18: 2902–7. 24 Tattersall MHN, Butow PN, Brown JE, Thompson JF. Improving doctors’ letters. Med J Aust 2002; 177: 516–20. 25 Clinical Guideline 27. Referral Guidelines for Suspected Cancer. www.nice.org.uk/CG027 (accessed 1 July 2013). 26 National Institute for Health and Clinical Excellence Clinical Guideline 131. (2011) Colorectal Cancer: The Diagnosis and Management of Colorectal Cancer. National Institute for Health and Clinical Excellence, London. 27 Desch CE, Benson AB 3rd, Somerfield MR et al. Colorectal cancer surveillance: 2005 update of an American Society of Clinical Oncology practice guideline. J Clin Oncol 2005; 23: 8512 9. (Erratum appears in J Clin Oncol 2006; 24: 1224.) 28 National Comprehensive Cancer Network (NCCN) Colon Cancer Panel. (2010) NCCN Clinical Practice Guidelines in Oncology. Colon Cancer V.3.2010 and Rectal Cancer V.3.2010. National Comprehensive Cancer Network. http://www.nccn.org/professionals/physician_gls/f_guide lines.asp (accessed 1 July 2013). 29 Malin JL, Schneider EC, Epstein AM, Adams J, Emanuel EJ, Kahn KL. Results of the National Initiative for Cancer Care Quality: how can we improve the quality of cancer care in the United States? J Clin Oncol 2006; 24: 626–34. 30 Cancer Institute NSW. (2011) Evaluation of the Role of Cancer Care Coordinator November 2011. Cancer Institute NSW, Sydney, NSW.
Commentary on Young et al.
Although the field of medicine has evolved considerably owing to revolutionary technological, pharmacological and therapeutic advances, it has continued to lag behind other industries in some areas. Thus, the innate need to streamline coordination so as to strengthen delivery of care, patient satisfaction and cost-effectiveness has only recently gained appreciation in the medical field. For cancer, the focus of the physician has traditionally revolved around processes targeted at ‘cure’ of the patient. There has been a great emphasis on prompt diagnosis, accurate staging, rapid control of disease and prevention of complications. Management algorithms and care pathways based on best available evidence have fostered these aims. Processes around ‘care’ of cancer
doi:10.1111/codi.12400
patients and their families have been less well developed, however. Most efforts in this direction have primarily related to the alleviation of suffering from cancer and the support of patients and families. The management of colorectal cancer has evolved into a truly multidisciplinary model. Several studies [1–3] suggest that the types of treatment modalities used, the order in which they are applied as well as the particular combinations of therapies influence outcomes depending upon tumour factors including the anatomical segment involved and the location and extent of disease, whether previous treatments were used and patient-related factors. Deviations from treatment guidelines have an adverse influence on the outcome for
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 17–27
25
J. M. Young et al.
Cancer care coordination measures
colorectal cancer [4]. Considering the complex interplay between the various factors that influence management and hence the outcome for a particular patient, coordination of care that optimizes treatment delivery across specialties and disciplines is of paramount importance. Whilst surgeons have championed a coordinated and concerted effort that allows the smooth execution of peri-operative processes to facilitate the preoperative, intra-operative and postoperative phases for patients undergoing surgery, they have lagged behind in the coordination of efforts in the multidisciplinary management of patients with colorectal cancer, a role currently better played by oncologists. The lack of reliable and reproducible metrics that track the efficacy of the coordination of care is a particular challenge when implementing and promoting measures in this direction. On the background of the foregoing, the work by Young et al. in this issue of Colorectal Disease to identify objective measures related to the coordination of the care of colorectal cancer is important and certainly refreshing. The authors used a two-stage Delphi technique whereby a 20-member expert panel reached a consensus on the validity of 15 out of 41 items that the authors identified as potential indicators for the coordination of colorectal cancer care. Consensus was reached in such areas as appropriateness of treatment and adherence to a clinical pathway, communication, multidisciplinary care and care planning. The specific measures in these areas that were identified as indicators of care coordination were legibility, clarity, content and timeliness of hospital discharge letters, documentation of the outcome of multidisciplinary team meetings, documentation of preoperative consultation with a stoma therapist, discussion and referral for adjuvant therapy for appropriate patients and treatment by an experienced colorectal surgeon. Consensus was not reached, however, on the validity of indicators relating to access and efficiency of services. Considering that the main goal of any cancer care coordination is to reduce time to and through care, this lack of consensus from the panel for any metric that could serve as an objective evaluation of timeliness of care is disappointing. Given that multiple patient, physician, institutional and social factors are likely to have an influence on when a patient with cancer is seen and evaluated by a specialist, and investigations or treatment commenced or completed, the ability to use these timelines as a measure for coordination of care may certainly be somewhat nebulous. The lack of established guidelines relating to the specifics of time-lines that would be considered ideal as well as the lack of strong evidence supporting any such existing recommendations for the
26
measures of interest included in the study could also be a particular problem. Thus, the expert panel may have had differences of opinion as to what constitutes adequacy of care. Notwithstanding these potential issues, the lack of consensus in the study could equally be due to the authors’ choice of the specific metrics identified as a yardstick for care coordination. A review of all the items chosen for inclusion in the questionnaire clearly confirms the likely inadequacy of the questionnaire and hence its potential shortcomings. Since the results of this study are derived from the use of the Delphi technique, some of the specifics of this methodology and its effect on the eventual findings are worth discussing. While the Delhi technique and its modifications have been widely used in such areas as industry, business and healthcare research, the process primarily involves achieving consensus in a given area of uncertainty. Thus, it has been suggested that the output from the Delphi method should be interpreted merely as an opinion [5] with the consequent associated disadvantages [6]. For a study such as that by Young et al., since the results are simply the consensus of an expert panel on a questionnaire, the quality of the output is determined by the robustness of the items included in the questionnaire as well as the expertise of the panel members. In this regard, since the items included by the authors were derived from a literature review, there is a risk for propagation of the same disadvantages of previous studies on the topic. In particular, some of the very factors that previous studies failed to identify and hence include would also be at risk of exclusion in the study. The addition of a more detailed qualitative approach for the initial identification of the items in the questionnaire would have allowed the inclusion of other robust as well as more real-world measures that could better reflect cancer care coordination. Regardless of these drawbacks, the identification of objective measures that evaluate cancer care coordination is challenging. While the authors chose to use the Delphi methodology similar to previous work [7], there are several limitations of this methodology [8] that may be circumvented in the future by other methods that seem to hold some promise [9]. As this relates to the eventual output of the study, the set of items identified by the authors can certainly be incorporated into any assessment of the appropriateness and degree of cancer coordination. The completeness of these identified measures as a stand-alone tool is questionable, however, and their validity and generalizability across systems and locations need to be established. The authors should be commended for expanding our knowledge in this important area of colorectal cancer care where there is a current dearth of
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 17–27
J. M. Young et al.
information. Their work will serve to generate debate and spur future advancements in the area that will further improve the management of patients with colorectal cancer.
Ravi P Kiran Division of Colorectal Surgery, Columbia University and the New York Presbyterian Hospital, New York, NY, USA E-mail: [email protected]
References 1 Petersen SH, Harling H, Kirkeby LT, Wille-Jørgensen P, Mocellin S. Postoperative adjuvant chemotherapy in rectal cancer operated for cure. Cochrane Database Syst Rev 2012; 3: CD004078. 2 Cartwright TH. Treatment decisions after diagnosis of metastatic colorectal cancer. Clin Colorectal Cancer 2012; 11: 155–66. 3 Kyriakou F, Kountourakis P, Papamichael D. Targeted agents: review of toxicity in the elderly metastatic colorectal cancer patients. Target Oncol 2011; 6: 245–51.
Cancer care coordination measures
4 Jullumstrø E, Wibe A, Lydersen S, Edna TH. Violation of treatment guidelines hazard for rectal cancer patients. Int J Colorectal Dis 2012; 27: 103–9. 5 Pill J. The Delphi method: substance, context, a critique and an annotated bibliography. Socio-Economic Planning Sci 1971; 5: 57–71. 6 Sackman H. (1975). Delphi Critique. Lexington Books, Boston, MA. 7 Young JM, Walsh J, Butow PN, Solomon MJ, Shaw J. Measuring cancer care coordination: development and validation of a questionnaire for patients. BMC Cancer 2011; 11: 298. 8 Powell C. The Delphi technique: myths and realities. J Adv Nurs 2003; 41: 376–82. 9 Collinson L, Kvizhinadze G, Foster R, Blakely T (2013). Care coordination services in colon cancer care: DES as a preferred option. In 9th World Congress on Health Economics: Celebrating Health Economics. Abstract.
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 17–27
27
Copyright of Colorectal Disease is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
13 Brook R. (1995). The RAND/UCLA Appropriateness Method. RAND, Santa Monica, CA. 14 Bilimoria K, Bentrem D, Lillemoe K, Talamonti MCK. Assessment of pancreatic cancer care in the United States based on formally developed quality indicators 2009. J Natl Cancer Inst 2009; 101: 848–59. 15 Earle CC. Failing to plan is planning to fail: improving the quality of care with survivorship care plans. J Clin Oncol 2006; 24: 5112–6. 16 King M, Jones L, McCarthy O et al. Development and pilot evaluation of a complex intervention to improve experienced continuity of care in patients with cancer. Br J Cancer 2008; 100: 274–80. 17 Smith SDM, Nicol KM, Devereux J, Cornbleet MA. Encounters with doctors: quantity and quality. Palliat Med 1999; 13: 217–23. 18 Schrag D, Cramer L, Bach PB, Cohen AM, Warren JL, Begg CB. Influence of hospital procedure volume on outcomes following surgery for colon cancer. JAMA 2000; 284: 3028–35. 19 Greenberg CC. Promoting quality surgical care the next steps. JAMA 2013; 309: 827–8. 20 Archampong D, Borowski D, Wille-Jørgensen P, Iversen LH. Workload and surgeon’s specialty for outcome after colorectal cancer surgery. Cochrane Database Syst Rev 2012; 3: CD005391. 21 van Gijn W, Gooiker GA, Wouters MW, Post PN, Tollenaar RA, van de Velde CJ. Volume and outcome in colorectal cancer surgery. Eur J Surg Oncol 2010; 36 (Suppl 1): S55 63. 22 Aubin M, Vezina L, Verreault R et al. Patient, primary care physician and specialist expectations of primary care physician involvement in cancer care. J Gen Intern Med 2012; 27: 8–15.
Cancer care coordination measures
23 Barnes EA, Hanson J, Neumann CM, Nekolaichuk CL, Bruera E. Communication between primary care physicians and radiation oncologists regarding patients with cancer treated with palliative radiotherapy. J Clin Oncol 2000; 18: 2902–7. 24 Tattersall MHN, Butow PN, Brown JE, Thompson JF. Improving doctors’ letters. Med J Aust 2002; 177: 516–20. 25 Clinical Guideline 27. Referral Guidelines for Suspected Cancer. www.nice.org.uk/CG027 (accessed 1 July 2013). 26 National Institute for Health and Clinical Excellence Clinical Guideline 131. (2011) Colorectal Cancer: The Diagnosis and Management of Colorectal Cancer. National Institute for Health and Clinical Excellence, London. 27 Desch CE, Benson AB 3rd, Somerfield MR et al. Colorectal cancer surveillance: 2005 update of an American Society of Clinical Oncology practice guideline. J Clin Oncol 2005; 23: 8512 9. (Erratum appears in J Clin Oncol 2006; 24: 1224.) 28 National Comprehensive Cancer Network (NCCN) Colon Cancer Panel. (2010) NCCN Clinical Practice Guidelines in Oncology. Colon Cancer V.3.2010 and Rectal Cancer V.3.2010. National Comprehensive Cancer Network. http://www.nccn.org/professionals/physician_gls/f_guide lines.asp (accessed 1 July 2013). 29 Malin JL, Schneider EC, Epstein AM, Adams J, Emanuel EJ, Kahn KL. Results of the National Initiative for Cancer Care Quality: how can we improve the quality of cancer care in the United States? J Clin Oncol 2006; 24: 626–34. 30 Cancer Institute NSW. (2011) Evaluation of the Role of Cancer Care Coordinator November 2011. Cancer Institute NSW, Sydney, NSW.
Commentary on Young et al.
Although the field of medicine has evolved considerably owing to revolutionary technological, pharmacological and therapeutic advances, it has continued to lag behind other industries in some areas. Thus, the innate need to streamline coordination so as to strengthen delivery of care, patient satisfaction and cost-effectiveness has only recently gained appreciation in the medical field. For cancer, the focus of the physician has traditionally revolved around processes targeted at ‘cure’ of the patient. There has been a great emphasis on prompt diagnosis, accurate staging, rapid control of disease and prevention of complications. Management algorithms and care pathways based on best available evidence have fostered these aims. Processes around ‘care’ of cancer
doi:10.1111/codi.12400
patients and their families have been less well developed, however. Most efforts in this direction have primarily related to the alleviation of suffering from cancer and the support of patients and families. The management of colorectal cancer has evolved into a truly multidisciplinary model. Several studies [1–3] suggest that the types of treatment modalities used, the order in which they are applied as well as the particular combinations of therapies influence outcomes depending upon tumour factors including the anatomical segment involved and the location and extent of disease, whether previous treatments were used and patient-related factors. Deviations from treatment guidelines have an adverse influence on the outcome for
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 17–27
25
J. M. Young et al.
Cancer care coordination measures
colorectal cancer [4]. Considering the complex interplay between the various factors that influence management and hence the outcome for a particular patient, coordination of care that optimizes treatment delivery across specialties and disciplines is of paramount importance. Whilst surgeons have championed a coordinated and concerted effort that allows the smooth execution of peri-operative processes to facilitate the preoperative, intra-operative and postoperative phases for patients undergoing surgery, they have lagged behind in the coordination of efforts in the multidisciplinary management of patients with colorectal cancer, a role currently better played by oncologists. The lack of reliable and reproducible metrics that track the efficacy of the coordination of care is a particular challenge when implementing and promoting measures in this direction. On the background of the foregoing, the work by Young et al. in this issue of Colorectal Disease to identify objective measures related to the coordination of the care of colorectal cancer is important and certainly refreshing. The authors used a two-stage Delphi technique whereby a 20-member expert panel reached a consensus on the validity of 15 out of 41 items that the authors identified as potential indicators for the coordination of colorectal cancer care. Consensus was reached in such areas as appropriateness of treatment and adherence to a clinical pathway, communication, multidisciplinary care and care planning. The specific measures in these areas that were identified as indicators of care coordination were legibility, clarity, content and timeliness of hospital discharge letters, documentation of the outcome of multidisciplinary team meetings, documentation of preoperative consultation with a stoma therapist, discussion and referral for adjuvant therapy for appropriate patients and treatment by an experienced colorectal surgeon. Consensus was not reached, however, on the validity of indicators relating to access and efficiency of services. Considering that the main goal of any cancer care coordination is to reduce time to and through care, this lack of consensus from the panel for any metric that could serve as an objective evaluation of timeliness of care is disappointing. Given that multiple patient, physician, institutional and social factors are likely to have an influence on when a patient with cancer is seen and evaluated by a specialist, and investigations or treatment commenced or completed, the ability to use these timelines as a measure for coordination of care may certainly be somewhat nebulous. The lack of established guidelines relating to the specifics of time-lines that would be considered ideal as well as the lack of strong evidence supporting any such existing recommendations for the
26
measures of interest included in the study could also be a particular problem. Thus, the expert panel may have had differences of opinion as to what constitutes adequacy of care. Notwithstanding these potential issues, the lack of consensus in the study could equally be due to the authors’ choice of the specific metrics identified as a yardstick for care coordination. A review of all the items chosen for inclusion in the questionnaire clearly confirms the likely inadequacy of the questionnaire and hence its potential shortcomings. Since the results of this study are derived from the use of the Delphi technique, some of the specifics of this methodology and its effect on the eventual findings are worth discussing. While the Delhi technique and its modifications have been widely used in such areas as industry, business and healthcare research, the process primarily involves achieving consensus in a given area of uncertainty. Thus, it has been suggested that the output from the Delphi method should be interpreted merely as an opinion [5] with the consequent associated disadvantages [6]. For a study such as that by Young et al., since the results are simply the consensus of an expert panel on a questionnaire, the quality of the output is determined by the robustness of the items included in the questionnaire as well as the expertise of the panel members. In this regard, since the items included by the authors were derived from a literature review, there is a risk for propagation of the same disadvantages of previous studies on the topic. In particular, some of the very factors that previous studies failed to identify and hence include would also be at risk of exclusion in the study. The addition of a more detailed qualitative approach for the initial identification of the items in the questionnaire would have allowed the inclusion of other robust as well as more real-world measures that could better reflect cancer care coordination. Regardless of these drawbacks, the identification of objective measures that evaluate cancer care coordination is challenging. While the authors chose to use the Delphi methodology similar to previous work [7], there are several limitations of this methodology [8] that may be circumvented in the future by other methods that seem to hold some promise [9]. As this relates to the eventual output of the study, the set of items identified by the authors can certainly be incorporated into any assessment of the appropriateness and degree of cancer coordination. The completeness of these identified measures as a stand-alone tool is questionable, however, and their validity and generalizability across systems and locations need to be established. The authors should be commended for expanding our knowledge in this important area of colorectal cancer care where there is a current dearth of
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 17–27
J. M. Young et al.
information. Their work will serve to generate debate and spur future advancements in the area that will further improve the management of patients with colorectal cancer.
Ravi P Kiran Division of Colorectal Surgery, Columbia University and the New York Presbyterian Hospital, New York, NY, USA E-mail: [email protected]
References 1 Petersen SH, Harling H, Kirkeby LT, Wille-Jørgensen P, Mocellin S. Postoperative adjuvant chemotherapy in rectal cancer operated for cure. Cochrane Database Syst Rev 2012; 3: CD004078. 2 Cartwright TH. Treatment decisions after diagnosis of metastatic colorectal cancer. Clin Colorectal Cancer 2012; 11: 155–66. 3 Kyriakou F, Kountourakis P, Papamichael D. Targeted agents: review of toxicity in the elderly metastatic colorectal cancer patients. Target Oncol 2011; 6: 245–51.
Cancer care coordination measures
4 Jullumstrø E, Wibe A, Lydersen S, Edna TH. Violation of treatment guidelines hazard for rectal cancer patients. Int J Colorectal Dis 2012; 27: 103–9. 5 Pill J. The Delphi method: substance, context, a critique and an annotated bibliography. Socio-Economic Planning Sci 1971; 5: 57–71. 6 Sackman H. (1975). Delphi Critique. Lexington Books, Boston, MA. 7 Young JM, Walsh J, Butow PN, Solomon MJ, Shaw J. Measuring cancer care coordination: development and validation of a questionnaire for patients. BMC Cancer 2011; 11: 298. 8 Powell C. The Delphi technique: myths and realities. J Adv Nurs 2003; 41: 376–82. 9 Collinson L, Kvizhinadze G, Foster R, Blakely T (2013). Care coordination services in colon cancer care: DES as a preferred option. In 9th World Congress on Health Economics: Celebrating Health Economics. Abstract.
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 17–27
27
Copyright of Colorectal Disease is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
