bs_bs_banner
Asia-Pacific Journal of Clinical Oncology 2015; 11: 152–159
doi: 10.1111/ajco.12327
ORIGINAL ARTICLE
Keeping primary care “in the loop”: General practitioners want better communication with specialists and hospitals when caring for people diagnosed with cancer Natalia LIZAMA,1,2 Claire E JOHNSON,2 Manonita GHOSH,2 Neeraj GARG,2* Jonathan D EMERY3† and Christobel SAUNDERS2 1
WA Cancer and Palliative Care Network, WA Department of Health, East Perth, 2School of Surgery, The University of Western Australia and 3School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, Western Australia, Australia
Abstract Aim: To investigate general practitioners’ (GP) perceptions about communication when providing cancer care. Methods: A self-report survey, which included an open response section, was mailed to a random sample of 1969 eligible Australian GPs. Content analysis of open response comments pertaining to communication was undertaken in order to ascertain GPs’ views about communication issues in the provision of cancer care. Results: Of the 648 GPs who completed the survey, 68 (10%) included open response comments about interprofessional communication. Participants who commented on communication were a median age of 50 years and worked 33 h/week; 28% were male and 59% practiced in the metropolitan area. Comments pertaining to communication were coded using five non-mutually exclusive categories: being kept in the loop; continuity of care; relationships with specialists; positive communication experiences; and strategies for improving communication.GPs repeatedly noted the importance of receiving detailed and timely communication from specialists and hospitals, particularly in relation to patients’ treatment regimes and follow-up care. Several GPs remarked that they were left out of “the information loop” and that patients were “lost” or “dumped” after referral. Conclusion: While many GPs are currently involved in some aspects of cancer management, detailed and timely communication between specialists and GPs is imperative to support shared care and ensure optimal patient outcomes. This research highlights the need for established channels of communication between specialist and primary care medicine to support greater involvement by GPs in cancer care. Key words: communication, delivery of health care, general practitioner, interprofessional relations, primary health care.
Correspondence: Dr Claire Johnson RN, PhD, School of Surgery M507, The University of Western Australia, 35 Stirling Highway, Crawley, WA 6009, Australia. Email: [email protected] *Present address: Ipswich Hospital, Heath Road Ipswich, Suffolk IP4 5PD, UK. † Present address: General Practice and Primary Care Academic Centre, University of Melbourne, 200 Berkeley Street, Carlton, Vic. 3053, Australia. Conflict of interest: The authors report no conflicts of interest
© 2015 Wiley Publishing Asia Pty Ltd
Previous presentation of the manuscript: A very brief summary of the qualitative results reported in detail in this manuscript was included in a paper published online in the Asia-Pacific Journal of Clinical Oncology in December 2012 (http://dx.doi.org/10.1111/ajco.12047). However, in view of the strength of comments made by GP participants regarding their concerns about interprofessional communication, the authors conducted a secondary analysis of the open response data. A preliminary analysis of these data was presented as a poster at the Clinical Oncology Society of Australia’s 39th Annual Scientific Meeting in November 2012. The poster abstract was published in the Asia-Pacific Journal of Clinical Oncology 2012;8(Suppl 3):324. Accepted for publication 15 October 2014.
153
Keeping primary care “in the loop”
INTRODUCTION As a result of the increasing incidence and prevalence of cancer in Australia,1 many cancer services face the challenge of caring for growing numbers of patients at different stages of their cancer journey. To help address the difficulties in providing comprehensive care for increasing numbers of people with a cancer diagnosis and with other chronic diseases, models of shared care across general practice and specialist services are encouraged.2,3 General practitioners (GPs) are typically involved in cancer prevention, screening, diagnosis, referral and palliative care, while cancer treatment is coordinated and provided by specialist services.4 However, GPs are central to a holistic approach to care. GPs, having established relationships with patients, are ideally placed to provide psychosocial support manage symptoms, monitor side effects of treatment and manage comorbidities.5–8 The role of the GP in treating cancer patients in rural and remote areas in Australia is especially important due to the significant distances involved in accessing cancer services.9 We undertook a cross-sectional survey of Australian GPs to investigate their preferences for being involved in the care of people diagnosed with cancer. We found that the majority of GPs wanted to be involved in most aspects of cancer prevention and management except for providing supportive care (52%), managing postoperative care (45%) or coordinating treatment (40%). GPs’ preference for involvement in more aspects of cancer management increased with GP age, if the GP practiced in rural compared with metropolitan areas, was a partner in a practice compared with sole practitioner, had previously received cancer-specific training or had indicated an interest in future training.10 In addition to the quantitative questions in this study, we invited participants to make open comments about GPs’ role in managing cancer. An important theme that emerged from the open comments of the survey related to communication and its importance to GPs when caring for people with cancer.10 The aim of this qualitative analysis was to identify key features of communication experiences of GPs in the shared management of people diagnosed with cancer.
METHODS A national cross-sectional survey of a random sample of 1969 GPs from across Australia was conducted using a self-report postal questionnaire, the methods of which are detailed elsewhere.10 At the end of the questionnaire,
Asia-Pac J Clin Oncol 2015; 11: 152–159
respondents were invited to make “any other comments about the role of general practitioners in the management of people with cancer.” We undertook qualitative analysis of all open comments made in response to this question.
Ethics approval Ethics approval was provided by the Human Research Ethics Committee at the University of Western Australia (Ref. No. RA/4/1/2547).
Qualitative analyses We conducted a qualitative inductive content analysis following the process described by Elo and Kyngäs in a review of qualitative content analysis methodology.11 In the “preparation” phase,11 CJ, NL and MG became “immersed in the data” by reading and rereading participants’ comments. In the “organization” phase, we created a number of subheadings while rereading through participants’ comments, which were then grouped hierarchically into categories and then main categories. Five categories were grouped under the main category of communication: being kept in the loop (in which participants discussed the need to receive timely information); continuity of care (in which participants discussed the importance of good communication for ongoing patient care); relationships with specialists (in which participants discussed feeling undervalued or unappreciated by specialists); positive communication (in which participants described positive working relationships or communication experiences); and communication strategies (in which participants offered suggestions for communication methods) (Fig. 1). Categories and names for categories “flowed” from the data, reflecting the inductive approach to analysis.12 Initial analysis was undertaken by MG and developed further by NL in consultation with CJ. Emergent themes were discussed in detail with authors CS and NG to confirm analysis. We report here on participants’ comments that were classified within the main category of communication.
Level of interest in cancer management An overall cancer management interest score for each participant was calculated from the questionnaire by adding the number of cancer management activities (prevention, diagnosis, postoperative management, coordination of treatment, provision of psychological support, coordination of supportive care, follow-up after treatment, monitoring for recurrence and palliative care) that GPs expressed an interest in being involved in
© 2015 Wiley Publishing Asia Pty Ltd
154
Figure 1
N Lizama et al.
Categories for participant comments about communication.
across seven cancer sites (breast, colorectal, hematological, lung, melanoma, prostate and upper gastrointestinal). The maximum total score was 62, as the question was in a grid format, and no response was permitted for prevention of hematological malignancies. These data are described in detail elsewhere.10 Scores were grouped in tertiles as low, medium or high interest in cancer care.
who discussed communication had a median age of 50 years and worked a median of 33 h/week; 59% practiced in metropolitan areas and more than half (56%) had not undertaken previous cancer-specific training or education in addition to their undergraduate and vocational training (Table 1).
Issues pertaining to communication
RESULTS Participants Completed surveys were received from 648 eligible GPs (consent rate 33%). Overall results of the survey are reported elsewhere.10 Open comments were made by 325 (50%) participants, of whom 68 (21%) commented on issues pertaining to communication. Participants
© 2015 Wiley Publishing Asia Pty Ltd
GPs who commented on issues pertaining to communication repeatedly emphasized the importance of effective communication with specialists and hospitals. While several participants described positive working relationships with nurses, allied health and specialists, most GPs expressed a need for improved communication. Table 2 presents representative quotes that demonstrate each of the key categories.
Asia-Pac J Clin Oncol 2015; 11: 152–159
155
Keeping primary care “in the loop”
Table 1 Participant demographics and personal characteristics Age (years) – median (IQ range) mean
50 (9) 50
Self-reported working hours per week – median (IQ range) mean
33 (20) 32
Location of practice Metropolitan Non-metropolitan Gender Male Female Type of practice Sole general practitioner Principal/group practice partner Contractor/registrar/employee Other Undertaken previous cancer management training Interested in undertaking cancer-specific training in the future Questionnaire score for interest in cancer care Low Medium High
Being kept “in the loop”. Participants identified the importance of keeping GPs “in the loop” and providing them with prompt and detailed information about patients’ care. GPs noted that it was difficult to provide care for cancer patients when they had received little or no information from hospitals and specialists (quote 1a, Table 2). GPs also emphasized the importance of receiving information about patients’ treatment, particularly in relation to chemotherapeutic regimes. Participants noted that when patients presented to their GPs with complications or side effects of treatment, GPs were often limited in their capacity to provide care by the fact that they had not been informed of what treatment the patient was undergoing (quotes 1a and 1b, Table 2). Participants felt that poor communication from specialists and hospitals reduced their capacity to be involved in patient care, noting that they felt excluded from the patient care team (quote 1d, Table 2). Participants who commented on the importance of keeping GPs in the loop tended to have a medium or high interest in cancer care. Continuity of care. Several participants described how they felt that specialists “dumped” patients into the care of GPs after they had “finished with them,” without giving GPs sufficient treatment and follow-up information to provide good follow-up care (quote 2a, Table 2).
Asia-Pac J Clin Oncol 2015; 11: 152–159
n
%
40 28
59 41
19 49
28 72
4 28 34 2 30 46
6 41 50 3 44 68
15 26 27
22 38 40
Participants also emphasized the importance of their role in explaining specialist information to patients, and reported that this was difficult when specialists failed to provide sufficient information to GPs (quote 2b, Table 2). The importance of providing information about treatment regimes and follow-up care was perceived to be particularly important by GPs practicing in rural areas (quote 2d, Table 2). Rural GPs highlighted the importance of receiving detailed and prompt information from specialists and hospitals regarding treatment plans and side effects, particularly where local services were limited or unavailable and GPs were responsible for managing care (quote 2e, Table 2). GPs who commented on the role of communication in relation to continuity of care tended to have medium or high interest in cancer care. Relationships with specialists. Several GPs described dissatisfaction with their relationships with secondary care providers, noting that they felt “underestimated,” “unappreciated,” “underutilized” and “undervalued” by specialists. Several GPs also felt that they were too often relegated to “clerical duties” at the behest of specialists, such as ordering tests and writing prescriptions and referrals (quotes 3a–3d, Table 2). GPs who reported feeling undervalued by specialists were more likely to
© 2015 Wiley Publishing Asia Pty Ltd
156
N Lizama et al.
Table 2 Key categories relating to general practitioners’ perceptions of communication and its importance when caring for people diagnosed with cancer – representative quotes 1. Being kept “in the loop” Quote 1a: My major issue is that when patients enter the hospital system all communication ceases – no copies of results, few letters – very little feedback. It’s as if hospital doctors don’t realise the real world exists but it’s us they call in the middle of the night. (ID1922, female, rural, undertaken cancer-specific training, high cancer care interest) Quote 1b: patients are often instructed to “return to GP for follow up” and we haven’t received information about their treatment, side effects expected and need for urgent review. (ID1343, female, metropolitan, no previous cancer-specific training, medium cancer care interest) Quote 1c: Too often patients are not sent back to GPs with sufficient information for the GP to be able to explain the care to the patient or to understand the possible side effects of treatment and necessary follow up – both short and long term. (ID694, female, metropolitan, no previous cancer-specific training, high cancer care interest) Quote 1d: And with the lack of timely communication from hospitals based services and the unfortunate tendency to leave the GP out of the “information loop”, the GP is not part of any “team” caring for patients. (ID262, female, metropolitan, no previous cancer-specific training, medium cancer care interest) 2. Continuity of care Quote 2a: There is a difference between being involved in the management of patients with cancer and being dumped with a patient by a specialist centre and not being able to get any information from that centre re treatment, follow up support etc. Do not confuse involving the GP with abdication by the specialist centre of their responsibilities to their patient. (ID904, female, rural, no previous cancer-specific training, low cancer care interest) Quote 2b: GPs are involved at all levels of care when patient is at home – often rely on patients giving the info on what is happening to them – just need to be kept informed and included in communication. (ID126, female, metropolitan, undertaken cancer-specific training, high cancer care interest) Quote 2c: General practitioners play an integral part in the diagnosis and coordination of cancer patients. Specialists handle most of the care. Henceforth, it is important for them to communicate with GPs as well. Proper communication and further instruction are needed to complete the care. There are cases where patients are just “dumped” to GPs and that is very sad. (ID1146, female, rural, no previous cancer-specific training, medium cancer care interest) Quote 2d: As I live in a rural/regional area, patients travel away for some parts of their care. I wish some specialists were better aware of the distances involved. (ID1150, female, rural, undertaken cancer-specific training, medium cancer care interest) Quote 2e: It would be helpful to receive a detailed treatment plan of drugs used, potential side effects, monitoring and management of side effects. As we are 45 km from the nearest hospital, we can be left managing complications, not knowing which regime the patient is on. (ID1131, female, rural, undertaken cancer-specific training, high cancer care interest) 3. Relationships with specialists Quote 3a: I would have no interest in becoming a specialist’s clerk – as a GP I am constantly being instructed by specialists’ secretaries to order tests, prescribe antibiotics, write referrals and see post-op patients when it is inconvenient for the specialist. A genuine, respected, remunerated role would be welcomed. (ID1609, male, metropolitan, undertaken cancer-specific training, high cancer care interest) Quote 3b: If I were to manage more of the cancer treatment etc. I would have to have an oncologist etc. available on the end of the phone and one that didn’t treat me as if he was too busy to talk to me. (ID1682, female, rural, undertaken cancer-specific training, high cancer care interest) Quote 3c: Most specialists underestimate the value of GP care. (ID1116, male, rural, undertaken cancer-specific training, low cancer care interest) Quote 3d: Too often relegated to being the person who fills out the forms! (ID345, female, rural, no previous cancer-specific training, high cancer care interest) 4. Positive experiences Quote 4a: I have seen a great improvement in our setting of coordinating cancer management (from diagnosis to palliative care). I think much of this is due to the establishment of our small but excellent oncology unit at the local regional hospital. (ID346, female, rural, no previous cancer-specific training, medium cancer care interest) Quote 4b: Fortunately we can access telephone help from palliation specialists. (ID1734, female, rural, undertaken cancer-specific training, medium cancer care interest) Quote 4c: I have a good working relationship with palliative care services. (ID73, female, metropolitan, no previous cancer-specific training, medium cancer care interest) Quote 4d: Correspondence with some surgeons to whom I have referred has been at times excellent. (ID416, female, metropolitan, no previous cancer-specific training, low cancer interest) Quote 4e: I have found the services provided by surgeons to be excellent Generally sufficient information is given to follow up care. (ID42, female, metropolitan, no previous cancer-specific training, low cancer care interest) 5. Strategies for improving communication Quote 5a: Progress reports are ideal so we “go through” treatment with the patient as we know them prior to them being “a cancer patient” and continue with them through life. (ID1566, female, rural, undertaken cancer-specific training, low cancer care interest) Quote 5b: If we were to provide follow up for recurrence we would need to be provided with flow charts/evidence based recommendations for that particular cancer. (ID1524, female, metropolitan, undertaken cancer-specific training, medium cancer care interest) Quote 5c: Telephone conversations and teleconferences using case conferences and discharge conferences would be greatly appreciated. (ID126, female, metropolitan, undertaken cancer-specific training, high cancer care interest) Quote 5d: Would appreciate more feedback during treatment when having chemotherapy and advice re complications to be on the lookout for and some accurate statistics re success rates of a given treatment to assist in counselling patients. (ID142, male, metropolitan, no previous cancer-specific training, medium cancer care interest) Quote 5e: Would appreciate easier access to oncologist/haematologist e.g. Ability to email oncologists for advice. (ID1456, male, rural, no previous cancer-specific training, medium cancer care interest)
© 2015 Wiley Publishing Asia Pty Ltd
Asia-Pac J Clin Oncol 2015; 11: 152–159
Keeping primary care “in the loop”
have a high level of interest in cancer care and to have undertaken cancer-specific training in addition to their undergraduate and vocational training. Positive experiences. While many participants emphasized the need for improved communication and relationships with specialists, a small number of GPs described positive experiences or effective modes of communication they had encountered. Several of these positive experiences related to GPs’ relationships with palliative care specialists (quotes 4b–4c, Table 2). GPs who described positive communication experiences tended to have a low or medium interest in cancer care. Strategies for improving communication. Several participants, while discussing the need for improved communication from specialists and hospitals, also put forward suggestions for improving communication. One GP suggested that progress reports from specialists and hospitals would enable them to enhance their understanding of patients’ treatment. GPs also suggested that information about prognosis and treatment would assist them in providing follow-up care and monitoring for recurrence (quotes 5a–5e, Table 2). Most participants who suggested strategies for improving communication had a medium level of interest in cancer care.
DISCUSSION To our knowledge, ours is the first Australia-wide study to explore GPs’ views about providing cancer care. Participants completing a survey about their interest in providing care for people diagnosed with cancer were invited to make any other comments about the role of GPs in cancer management of people with cancer. In this section, 68 participants flagged the quality and timeliness of communication as key factors that affected the capacity of GPs to provide care to cancer patients during cancer treatment, follow-up and monitoring. Although it might be assumed that having positive communication experiences would make GPs more enthusiastic about providing cancer care, most GPs who included comments about their positive communication experiences had a low or medium interest in cancer care. It may be the case that GPs who report positive communication experiences are actually less involved in cancer care than their more negative counterparts. If so, then these GPs may have less of a need for high-quality communication when compared with those GPs who are more involved in cancer care. This would seem to be supported by the fact that most GPs who reported
Asia-Pac J Clin Oncol 2015; 11: 152–159
157
feeling undervalued or underestimated had undertaken additional cancer-specific training, suggesting that they felt that their knowledge and experience in cancer care was underutilized and not adequately recognized by specialists. The fact that most GPs who felt undervalued or underestimated had a high interest in cancer care also suggests that those GPs who are already more involved in cancer care may feel that their relationships and communication with specialists and hospitals need improvement. GPs’ concerns about the quality of communication between specialists and primary care providers are not unique to our study. Communication from hospitals and specialists to GPs often does not provide information about the overall treatment plan and the potential side effects that patients are likely to experience.13 Previous research has found that delayed or insufficient information limits GPs’ ability to provide optimal patient care.14 Furthermore, poor interprofessional communication can hamper continuity of care and lead to fragmented care.15 Mitchell et al. found that contact is often delayed and, as a consequence, GPs rely on patients themselves to provide information about their diagnosis and treatment. While patients may be able to report some information to their GPs, it may be inaccurate and incomplete.16 Our findings highlight the frustration and difficulties encountered by GPs in providing patients with the information, care and support they require and ensuring that patients do not get lost in the complexities of the health care system when GPs themselves have incomplete information. To encourage and support GPs in actively sharing the care of cancer patients, timely transfer of relevant information between primary care providers and specialists is essential. Indeed, poor communication and information sharing has previously been identified as important barrier to GPs adopting a more active role in caring for people with a cancer diagnosis,17,18 and one that may limit their ability to provide high-quality care.14 While there is ongoing research about shared care in cancer,19 few health services can demonstrate a systematic approach to comprehensive information sharing embedded in practice. Communication between GPs and specialists often follows the traditional approach of interprofessional letters and discharge summaries, which are not unusually delayed and may or may not contain the level of information required by the GP.13,14 A recent review of the role of primary care in the management of people diagnosed with cancer recommended early contact with the patient’s primary care provider at the time of discharge by specialist services. Information
© 2015 Wiley Publishing Asia Pty Ltd
158
should be provided about the treatment and follow-up plans as well as the management of adverse events how and when to access specialist support.20 Studies have investigated a number of methods of transferring information, such as the use of patient-held records,21 case conferencing,16 faxed treatment regimes,22 structured information packs23 and use of electronic health records.24 Despite reports that such programs result in numerous benefits – including improved sharing of information, increased collaboration, GPs being better equipped to provide care, more coordinated care and higher GP satisfaction with the secondary provider – there has not been universal uptake due to the lack of a systematic processes for embedding them into routine practice at an institutional level and across health jurisdictions. Frequently, the success of projects is dependent on the interpersonal and communication skills of individuals involved, rather than a process being systematically implemented.25 E-health initiatives have been identified as an approach that will potentially improve many of the identified concerns about communication between health professionals and across institutions.26 However, implementation of such programs has been hampered by concerns relating to e-health’s effects on the roles and responsibilities of health professionals, management of risks associated with its use, transparency in its use27,28 and the costeffectiveness of such programs.29 Nevertheless, locally implemented e-health programs have resulted in improved access to information about patients’ treatment regimes and follow-up requirements for GPs. While attempts to embed e-health programs across jurisdictions, such as the Australian Personally Controlled Electronic Health Records for All Australians initiative, are slow to be implemented and are hampered by limited consumer use,30 it is anticipated that they will contribute to more effective information sharing and facilitate greater primary sector involvement in the management of people diagnosed with cancer. There are a number of limitations that may affect the generalizability of our study. Our response rate for the national survey (33%) was lower than expected, and although our sample size was large enough to ascertain differences between all participants, the number of participants who commented on issues pertaining to communication was relatively small. As outlined elsewhere, our sample is representative of all Australian GPs in terms of geographical location, and similar in terms of age and hours worked per week.10 However, participants who provided open comments about communication issues worked fewer hours, and were more likely to
© 2015 Wiley Publishing Asia Pty Ltd
N Lizama et al.
be female and working in nonmetropolitan areas. It is also possible that GPs who were frustrated with the quality of communication they received from specialists and hospitals were more likely to include comments that described negative experiences or feeling undervalued. Hence, open comments may not be representative of all GPs, but nonetheless reflect the frustrations of GPs for whom communication is particularly important, such as those from nonmetropolitan areas and those who are more interested in cancer care. A further limitation is that our research was limited to the comments that participants included in the survey, so we were unable to explore participants’ views in greater depth; as such, our analysis may be less comprehensive and complex than if we had undertaken participant interviews. However, despite these limitations, our study provides important information about GPs’ experiences of communication when delivering cancer care.
CONCLUSION Timely information sharing and communication, as well as development of collaborative interprofessional relationships, is important to engage GPs in cancer care – especially GPs who have a higher level of interest in helping to provide care for people diagnosed with cancer.
ACKNOWLEDGMENTS We would like to express our appreciation to the Australian general practitioners who completed the Preferences for Managing Patients Diagnosed with Cancer questionnaire and who made further comments about their experiences. This research was funded by the Cancer and Palliative Care Research and Evaluation Unit (CaPCREU), which is a collaboration between Curtin University, Edith Cowan University and The University of Western Australia. CaPCREU was established with funding from the Western Australian Government Department of Health through the WA Cancer and Palliative Care Network. The views expressed in this paper are not necessarily those of the WA Cancer and Palliative Care Network.
REFERENCES 1 Australian Institute of Health and Welfare. Older Australia at a Glance. Canberra: Australian Institute of Health and Welfare, Australian Government Department of Health and Ageing, 2002.
Asia-Pac J Clin Oncol 2015; 11: 152–159
Keeping primary care “in the loop”
2 National Health and Hospitals Reform Commission. A Healthier Future for All Australians – Final Report of the National Health and Hospitals Reform Commission. Canberra, 2009; 107. 3 Weller DP, Harris MF. Cancer care: what role for the general practitioner? Med J Aust 2008; 189: 59–60. 4 McAvoy B. General practitioners and cancer control. Med J Aust 2007; 187: 115–7. 5 Grunfeld E, Mant D, Yudkin P et al. Routine follow-up of breast cancer in primary care: randomised trial. Br Med J 1996; 313: 665–9. 6 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 2006; 24: 848–55. 7 Mahboubi A, Lejeune C, Coriat R et al. Which patients with colorectal cancer are followed up by general practitioners? A population-based study. Eur J Cancer Prev 2007; 16: 535–41. 8 Wattchow D, Weller D, Esterman A et al. General practice versus surgical-based follow-up for patients with colon cancer: randomised controlled trial. Br J Cancer 2006; 94: 1116–21. 9 Hanks H, Veitch P, Harris M. A rural/urban comparison of the roles of the general practitioner in colorectal cancer management. Aust J Rural Health 2008; 16: 376–82. 10 Johnson CE, Lizama N, Garg N, Ghosh M, Emery J, Saunders C. Australian general practitioners’ preferences for managing the care of people diagnosed with cancer. Asia Pac J Clin Oncol 2014; 10: e90–8. 11 Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs 2008; 62: 107–15. 12 Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005; 15: 1277–88. 13 McConnell D, Butow PN, Tattersall MHN. Improving the letters we write: an exploration of doctor-doctor communication in cancer care. Br J Cancer 1999; 80: 427–37. 14 O’Malley AS, Reschovsky JD. Referral and consultation communication between primary care and specialist physicians: finding common ground. Arch Intern Med 2011; 171: 56–65. 15 Nazareth I, Jones L, Irving A et al. Perceived concepts of continuity of care in people with colorectal and breast cancer – a qualitative case study analysis. Eur J Cancer Care (Engl) 2008; 17: 569–77. 16 Mitchell G, Cherry M, Kennedy R et al. General practitioner, specialist providers case conferences in palliative care. Aust Fam Physician 2005; 34: 389–92. 17 Lewis RA, Neal RD, Williams NH et al. Follow-up of cancer in primary care versus secondary care: systematic review. Br J Gen Pract 2009; 59: e234–47.
Asia-Pac J Clin Oncol 2015; 11: 152–159
159
18 Shipman C, Addington-Hall J, Barclay S et al. How and why do GPs use specialist palliative care services? Palliat Med 2002; 16: 241–6. 19 Smith S, Allwright S, O’Dowd T. Effectiveness of shared care across the interface between primary and specialty care in chronic disease management (Review). Cochrane Database Syst Rev 2009; 18: CD004910. 20 Emery J, Trevena L, Mazza D et al. The role of primary and community-based healthcare professionals in early detection and follow-up in cancer care – a rapid review of best practice models. Evidence Check rapid review Sax Institute, Cancer Institute NSW, Primary Care Collaborative Cancer Clinical Trials Group, 2012. 21 Gysels M, Richardson A, Higginson IJ. Does the patientheld record improve continuity and related outcomes in cancer care: a systematic review. Health Expect 2007; 10: 75–91. 22 Jefford M, Baravelli C, Dudgeon P et al. Tailored chemotherapy information faxed to general practitioners improves confidence in managing adverse effects and satisfaction with shared care: results from a randomized controlled trial. J Clin Oncol 2008; 26: 2272–7. 23 Kousgaard KR, Nielsen JD, Olesen F, Jensen AB. General practitioner assessment of structured oncological information accompanying newly referred cancer patients. Scand J Prim Health Care 2003; 21: 110–4. 24 Schoen C, Osborn R, Squires D et al. A survey of primary care doctors in ten countries shows progress in use of health information technology, less in other areas. Health Aff 2012; 31: 2805–16. 25 Gardiner C, Gott M, Ingleton C. Factors supporting good partnership working between generalist and specialist palliative care services: a systematic review. Br J Gen Pract 2012; 62: e353–62. 26 Sada YH, Street RL Jr, Singh H, Shada RE, Naik AD. Primary care and communication in shared cancer care: a qualitative study. Am J Manag Care 2011; 17: 259–65. 27 Fontaine P, Ross SE, Zink T, Schilling LM. Systematic review of health information exchange in primary care practices. J Am Board Fam Med 2010; 23: 655–70. 28 Mair FS, May C, O’Donnell C, Finch T, Sullivan F, Murray E. Factors that promote or inhibit the implementation of e-health systems: an explanatory systematic review. Bull World Health Organ 2012; 90: 357–64. 29 Black AD, Car J, Pagliari C et al. The impact of ehealth on the quality and safety of health care: a systematic overview. PLoS Med 2011; 8: e1000387. 30 National E-Health Transition Authority. NEHTA Scorecard August 2013. [Cited 10/08/2014.] Available from URL: http://www.nehta.gov.au/media-centre/news/445nehta-ehealth-scorecard, 2013.
© 2015 Wiley Publishing Asia Pty Ltd
Asia-Pacific Journal of Clinical Oncology 2015; 11: 152–159
doi: 10.1111/ajco.12327
ORIGINAL ARTICLE
Keeping primary care “in the loop”: General practitioners want better communication with specialists and hospitals when caring for people diagnosed with cancer Natalia LIZAMA,1,2 Claire E JOHNSON,2 Manonita GHOSH,2 Neeraj GARG,2* Jonathan D EMERY3† and Christobel SAUNDERS2 1
WA Cancer and Palliative Care Network, WA Department of Health, East Perth, 2School of Surgery, The University of Western Australia and 3School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, Western Australia, Australia
Abstract Aim: To investigate general practitioners’ (GP) perceptions about communication when providing cancer care. Methods: A self-report survey, which included an open response section, was mailed to a random sample of 1969 eligible Australian GPs. Content analysis of open response comments pertaining to communication was undertaken in order to ascertain GPs’ views about communication issues in the provision of cancer care. Results: Of the 648 GPs who completed the survey, 68 (10%) included open response comments about interprofessional communication. Participants who commented on communication were a median age of 50 years and worked 33 h/week; 28% were male and 59% practiced in the metropolitan area. Comments pertaining to communication were coded using five non-mutually exclusive categories: being kept in the loop; continuity of care; relationships with specialists; positive communication experiences; and strategies for improving communication.GPs repeatedly noted the importance of receiving detailed and timely communication from specialists and hospitals, particularly in relation to patients’ treatment regimes and follow-up care. Several GPs remarked that they were left out of “the information loop” and that patients were “lost” or “dumped” after referral. Conclusion: While many GPs are currently involved in some aspects of cancer management, detailed and timely communication between specialists and GPs is imperative to support shared care and ensure optimal patient outcomes. This research highlights the need for established channels of communication between specialist and primary care medicine to support greater involvement by GPs in cancer care. Key words: communication, delivery of health care, general practitioner, interprofessional relations, primary health care.
Correspondence: Dr Claire Johnson RN, PhD, School of Surgery M507, The University of Western Australia, 35 Stirling Highway, Crawley, WA 6009, Australia. Email: [email protected] *Present address: Ipswich Hospital, Heath Road Ipswich, Suffolk IP4 5PD, UK. † Present address: General Practice and Primary Care Academic Centre, University of Melbourne, 200 Berkeley Street, Carlton, Vic. 3053, Australia. Conflict of interest: The authors report no conflicts of interest
© 2015 Wiley Publishing Asia Pty Ltd
Previous presentation of the manuscript: A very brief summary of the qualitative results reported in detail in this manuscript was included in a paper published online in the Asia-Pacific Journal of Clinical Oncology in December 2012 (http://dx.doi.org/10.1111/ajco.12047). However, in view of the strength of comments made by GP participants regarding their concerns about interprofessional communication, the authors conducted a secondary analysis of the open response data. A preliminary analysis of these data was presented as a poster at the Clinical Oncology Society of Australia’s 39th Annual Scientific Meeting in November 2012. The poster abstract was published in the Asia-Pacific Journal of Clinical Oncology 2012;8(Suppl 3):324. Accepted for publication 15 October 2014.
153
Keeping primary care “in the loop”
INTRODUCTION As a result of the increasing incidence and prevalence of cancer in Australia,1 many cancer services face the challenge of caring for growing numbers of patients at different stages of their cancer journey. To help address the difficulties in providing comprehensive care for increasing numbers of people with a cancer diagnosis and with other chronic diseases, models of shared care across general practice and specialist services are encouraged.2,3 General practitioners (GPs) are typically involved in cancer prevention, screening, diagnosis, referral and palliative care, while cancer treatment is coordinated and provided by specialist services.4 However, GPs are central to a holistic approach to care. GPs, having established relationships with patients, are ideally placed to provide psychosocial support manage symptoms, monitor side effects of treatment and manage comorbidities.5–8 The role of the GP in treating cancer patients in rural and remote areas in Australia is especially important due to the significant distances involved in accessing cancer services.9 We undertook a cross-sectional survey of Australian GPs to investigate their preferences for being involved in the care of people diagnosed with cancer. We found that the majority of GPs wanted to be involved in most aspects of cancer prevention and management except for providing supportive care (52%), managing postoperative care (45%) or coordinating treatment (40%). GPs’ preference for involvement in more aspects of cancer management increased with GP age, if the GP practiced in rural compared with metropolitan areas, was a partner in a practice compared with sole practitioner, had previously received cancer-specific training or had indicated an interest in future training.10 In addition to the quantitative questions in this study, we invited participants to make open comments about GPs’ role in managing cancer. An important theme that emerged from the open comments of the survey related to communication and its importance to GPs when caring for people with cancer.10 The aim of this qualitative analysis was to identify key features of communication experiences of GPs in the shared management of people diagnosed with cancer.
METHODS A national cross-sectional survey of a random sample of 1969 GPs from across Australia was conducted using a self-report postal questionnaire, the methods of which are detailed elsewhere.10 At the end of the questionnaire,
Asia-Pac J Clin Oncol 2015; 11: 152–159
respondents were invited to make “any other comments about the role of general practitioners in the management of people with cancer.” We undertook qualitative analysis of all open comments made in response to this question.
Ethics approval Ethics approval was provided by the Human Research Ethics Committee at the University of Western Australia (Ref. No. RA/4/1/2547).
Qualitative analyses We conducted a qualitative inductive content analysis following the process described by Elo and Kyngäs in a review of qualitative content analysis methodology.11 In the “preparation” phase,11 CJ, NL and MG became “immersed in the data” by reading and rereading participants’ comments. In the “organization” phase, we created a number of subheadings while rereading through participants’ comments, which were then grouped hierarchically into categories and then main categories. Five categories were grouped under the main category of communication: being kept in the loop (in which participants discussed the need to receive timely information); continuity of care (in which participants discussed the importance of good communication for ongoing patient care); relationships with specialists (in which participants discussed feeling undervalued or unappreciated by specialists); positive communication (in which participants described positive working relationships or communication experiences); and communication strategies (in which participants offered suggestions for communication methods) (Fig. 1). Categories and names for categories “flowed” from the data, reflecting the inductive approach to analysis.12 Initial analysis was undertaken by MG and developed further by NL in consultation with CJ. Emergent themes were discussed in detail with authors CS and NG to confirm analysis. We report here on participants’ comments that were classified within the main category of communication.
Level of interest in cancer management An overall cancer management interest score for each participant was calculated from the questionnaire by adding the number of cancer management activities (prevention, diagnosis, postoperative management, coordination of treatment, provision of psychological support, coordination of supportive care, follow-up after treatment, monitoring for recurrence and palliative care) that GPs expressed an interest in being involved in
© 2015 Wiley Publishing Asia Pty Ltd
154
Figure 1
N Lizama et al.
Categories for participant comments about communication.
across seven cancer sites (breast, colorectal, hematological, lung, melanoma, prostate and upper gastrointestinal). The maximum total score was 62, as the question was in a grid format, and no response was permitted for prevention of hematological malignancies. These data are described in detail elsewhere.10 Scores were grouped in tertiles as low, medium or high interest in cancer care.
who discussed communication had a median age of 50 years and worked a median of 33 h/week; 59% practiced in metropolitan areas and more than half (56%) had not undertaken previous cancer-specific training or education in addition to their undergraduate and vocational training (Table 1).
Issues pertaining to communication
RESULTS Participants Completed surveys were received from 648 eligible GPs (consent rate 33%). Overall results of the survey are reported elsewhere.10 Open comments were made by 325 (50%) participants, of whom 68 (21%) commented on issues pertaining to communication. Participants
© 2015 Wiley Publishing Asia Pty Ltd
GPs who commented on issues pertaining to communication repeatedly emphasized the importance of effective communication with specialists and hospitals. While several participants described positive working relationships with nurses, allied health and specialists, most GPs expressed a need for improved communication. Table 2 presents representative quotes that demonstrate each of the key categories.
Asia-Pac J Clin Oncol 2015; 11: 152–159
155
Keeping primary care “in the loop”
Table 1 Participant demographics and personal characteristics Age (years) – median (IQ range) mean
50 (9) 50
Self-reported working hours per week – median (IQ range) mean
33 (20) 32
Location of practice Metropolitan Non-metropolitan Gender Male Female Type of practice Sole general practitioner Principal/group practice partner Contractor/registrar/employee Other Undertaken previous cancer management training Interested in undertaking cancer-specific training in the future Questionnaire score for interest in cancer care Low Medium High
Being kept “in the loop”. Participants identified the importance of keeping GPs “in the loop” and providing them with prompt and detailed information about patients’ care. GPs noted that it was difficult to provide care for cancer patients when they had received little or no information from hospitals and specialists (quote 1a, Table 2). GPs also emphasized the importance of receiving information about patients’ treatment, particularly in relation to chemotherapeutic regimes. Participants noted that when patients presented to their GPs with complications or side effects of treatment, GPs were often limited in their capacity to provide care by the fact that they had not been informed of what treatment the patient was undergoing (quotes 1a and 1b, Table 2). Participants felt that poor communication from specialists and hospitals reduced their capacity to be involved in patient care, noting that they felt excluded from the patient care team (quote 1d, Table 2). Participants who commented on the importance of keeping GPs in the loop tended to have a medium or high interest in cancer care. Continuity of care. Several participants described how they felt that specialists “dumped” patients into the care of GPs after they had “finished with them,” without giving GPs sufficient treatment and follow-up information to provide good follow-up care (quote 2a, Table 2).
Asia-Pac J Clin Oncol 2015; 11: 152–159
n
%
40 28
59 41
19 49
28 72
4 28 34 2 30 46
6 41 50 3 44 68
15 26 27
22 38 40
Participants also emphasized the importance of their role in explaining specialist information to patients, and reported that this was difficult when specialists failed to provide sufficient information to GPs (quote 2b, Table 2). The importance of providing information about treatment regimes and follow-up care was perceived to be particularly important by GPs practicing in rural areas (quote 2d, Table 2). Rural GPs highlighted the importance of receiving detailed and prompt information from specialists and hospitals regarding treatment plans and side effects, particularly where local services were limited or unavailable and GPs were responsible for managing care (quote 2e, Table 2). GPs who commented on the role of communication in relation to continuity of care tended to have medium or high interest in cancer care. Relationships with specialists. Several GPs described dissatisfaction with their relationships with secondary care providers, noting that they felt “underestimated,” “unappreciated,” “underutilized” and “undervalued” by specialists. Several GPs also felt that they were too often relegated to “clerical duties” at the behest of specialists, such as ordering tests and writing prescriptions and referrals (quotes 3a–3d, Table 2). GPs who reported feeling undervalued by specialists were more likely to
© 2015 Wiley Publishing Asia Pty Ltd
156
N Lizama et al.
Table 2 Key categories relating to general practitioners’ perceptions of communication and its importance when caring for people diagnosed with cancer – representative quotes 1. Being kept “in the loop” Quote 1a: My major issue is that when patients enter the hospital system all communication ceases – no copies of results, few letters – very little feedback. It’s as if hospital doctors don’t realise the real world exists but it’s us they call in the middle of the night. (ID1922, female, rural, undertaken cancer-specific training, high cancer care interest) Quote 1b: patients are often instructed to “return to GP for follow up” and we haven’t received information about their treatment, side effects expected and need for urgent review. (ID1343, female, metropolitan, no previous cancer-specific training, medium cancer care interest) Quote 1c: Too often patients are not sent back to GPs with sufficient information for the GP to be able to explain the care to the patient or to understand the possible side effects of treatment and necessary follow up – both short and long term. (ID694, female, metropolitan, no previous cancer-specific training, high cancer care interest) Quote 1d: And with the lack of timely communication from hospitals based services and the unfortunate tendency to leave the GP out of the “information loop”, the GP is not part of any “team” caring for patients. (ID262, female, metropolitan, no previous cancer-specific training, medium cancer care interest) 2. Continuity of care Quote 2a: There is a difference between being involved in the management of patients with cancer and being dumped with a patient by a specialist centre and not being able to get any information from that centre re treatment, follow up support etc. Do not confuse involving the GP with abdication by the specialist centre of their responsibilities to their patient. (ID904, female, rural, no previous cancer-specific training, low cancer care interest) Quote 2b: GPs are involved at all levels of care when patient is at home – often rely on patients giving the info on what is happening to them – just need to be kept informed and included in communication. (ID126, female, metropolitan, undertaken cancer-specific training, high cancer care interest) Quote 2c: General practitioners play an integral part in the diagnosis and coordination of cancer patients. Specialists handle most of the care. Henceforth, it is important for them to communicate with GPs as well. Proper communication and further instruction are needed to complete the care. There are cases where patients are just “dumped” to GPs and that is very sad. (ID1146, female, rural, no previous cancer-specific training, medium cancer care interest) Quote 2d: As I live in a rural/regional area, patients travel away for some parts of their care. I wish some specialists were better aware of the distances involved. (ID1150, female, rural, undertaken cancer-specific training, medium cancer care interest) Quote 2e: It would be helpful to receive a detailed treatment plan of drugs used, potential side effects, monitoring and management of side effects. As we are 45 km from the nearest hospital, we can be left managing complications, not knowing which regime the patient is on. (ID1131, female, rural, undertaken cancer-specific training, high cancer care interest) 3. Relationships with specialists Quote 3a: I would have no interest in becoming a specialist’s clerk – as a GP I am constantly being instructed by specialists’ secretaries to order tests, prescribe antibiotics, write referrals and see post-op patients when it is inconvenient for the specialist. A genuine, respected, remunerated role would be welcomed. (ID1609, male, metropolitan, undertaken cancer-specific training, high cancer care interest) Quote 3b: If I were to manage more of the cancer treatment etc. I would have to have an oncologist etc. available on the end of the phone and one that didn’t treat me as if he was too busy to talk to me. (ID1682, female, rural, undertaken cancer-specific training, high cancer care interest) Quote 3c: Most specialists underestimate the value of GP care. (ID1116, male, rural, undertaken cancer-specific training, low cancer care interest) Quote 3d: Too often relegated to being the person who fills out the forms! (ID345, female, rural, no previous cancer-specific training, high cancer care interest) 4. Positive experiences Quote 4a: I have seen a great improvement in our setting of coordinating cancer management (from diagnosis to palliative care). I think much of this is due to the establishment of our small but excellent oncology unit at the local regional hospital. (ID346, female, rural, no previous cancer-specific training, medium cancer care interest) Quote 4b: Fortunately we can access telephone help from palliation specialists. (ID1734, female, rural, undertaken cancer-specific training, medium cancer care interest) Quote 4c: I have a good working relationship with palliative care services. (ID73, female, metropolitan, no previous cancer-specific training, medium cancer care interest) Quote 4d: Correspondence with some surgeons to whom I have referred has been at times excellent. (ID416, female, metropolitan, no previous cancer-specific training, low cancer interest) Quote 4e: I have found the services provided by surgeons to be excellent Generally sufficient information is given to follow up care. (ID42, female, metropolitan, no previous cancer-specific training, low cancer care interest) 5. Strategies for improving communication Quote 5a: Progress reports are ideal so we “go through” treatment with the patient as we know them prior to them being “a cancer patient” and continue with them through life. (ID1566, female, rural, undertaken cancer-specific training, low cancer care interest) Quote 5b: If we were to provide follow up for recurrence we would need to be provided with flow charts/evidence based recommendations for that particular cancer. (ID1524, female, metropolitan, undertaken cancer-specific training, medium cancer care interest) Quote 5c: Telephone conversations and teleconferences using case conferences and discharge conferences would be greatly appreciated. (ID126, female, metropolitan, undertaken cancer-specific training, high cancer care interest) Quote 5d: Would appreciate more feedback during treatment when having chemotherapy and advice re complications to be on the lookout for and some accurate statistics re success rates of a given treatment to assist in counselling patients. (ID142, male, metropolitan, no previous cancer-specific training, medium cancer care interest) Quote 5e: Would appreciate easier access to oncologist/haematologist e.g. Ability to email oncologists for advice. (ID1456, male, rural, no previous cancer-specific training, medium cancer care interest)
© 2015 Wiley Publishing Asia Pty Ltd
Asia-Pac J Clin Oncol 2015; 11: 152–159
Keeping primary care “in the loop”
have a high level of interest in cancer care and to have undertaken cancer-specific training in addition to their undergraduate and vocational training. Positive experiences. While many participants emphasized the need for improved communication and relationships with specialists, a small number of GPs described positive experiences or effective modes of communication they had encountered. Several of these positive experiences related to GPs’ relationships with palliative care specialists (quotes 4b–4c, Table 2). GPs who described positive communication experiences tended to have a low or medium interest in cancer care. Strategies for improving communication. Several participants, while discussing the need for improved communication from specialists and hospitals, also put forward suggestions for improving communication. One GP suggested that progress reports from specialists and hospitals would enable them to enhance their understanding of patients’ treatment. GPs also suggested that information about prognosis and treatment would assist them in providing follow-up care and monitoring for recurrence (quotes 5a–5e, Table 2). Most participants who suggested strategies for improving communication had a medium level of interest in cancer care.
DISCUSSION To our knowledge, ours is the first Australia-wide study to explore GPs’ views about providing cancer care. Participants completing a survey about their interest in providing care for people diagnosed with cancer were invited to make any other comments about the role of GPs in cancer management of people with cancer. In this section, 68 participants flagged the quality and timeliness of communication as key factors that affected the capacity of GPs to provide care to cancer patients during cancer treatment, follow-up and monitoring. Although it might be assumed that having positive communication experiences would make GPs more enthusiastic about providing cancer care, most GPs who included comments about their positive communication experiences had a low or medium interest in cancer care. It may be the case that GPs who report positive communication experiences are actually less involved in cancer care than their more negative counterparts. If so, then these GPs may have less of a need for high-quality communication when compared with those GPs who are more involved in cancer care. This would seem to be supported by the fact that most GPs who reported
Asia-Pac J Clin Oncol 2015; 11: 152–159
157
feeling undervalued or underestimated had undertaken additional cancer-specific training, suggesting that they felt that their knowledge and experience in cancer care was underutilized and not adequately recognized by specialists. The fact that most GPs who felt undervalued or underestimated had a high interest in cancer care also suggests that those GPs who are already more involved in cancer care may feel that their relationships and communication with specialists and hospitals need improvement. GPs’ concerns about the quality of communication between specialists and primary care providers are not unique to our study. Communication from hospitals and specialists to GPs often does not provide information about the overall treatment plan and the potential side effects that patients are likely to experience.13 Previous research has found that delayed or insufficient information limits GPs’ ability to provide optimal patient care.14 Furthermore, poor interprofessional communication can hamper continuity of care and lead to fragmented care.15 Mitchell et al. found that contact is often delayed and, as a consequence, GPs rely on patients themselves to provide information about their diagnosis and treatment. While patients may be able to report some information to their GPs, it may be inaccurate and incomplete.16 Our findings highlight the frustration and difficulties encountered by GPs in providing patients with the information, care and support they require and ensuring that patients do not get lost in the complexities of the health care system when GPs themselves have incomplete information. To encourage and support GPs in actively sharing the care of cancer patients, timely transfer of relevant information between primary care providers and specialists is essential. Indeed, poor communication and information sharing has previously been identified as important barrier to GPs adopting a more active role in caring for people with a cancer diagnosis,17,18 and one that may limit their ability to provide high-quality care.14 While there is ongoing research about shared care in cancer,19 few health services can demonstrate a systematic approach to comprehensive information sharing embedded in practice. Communication between GPs and specialists often follows the traditional approach of interprofessional letters and discharge summaries, which are not unusually delayed and may or may not contain the level of information required by the GP.13,14 A recent review of the role of primary care in the management of people diagnosed with cancer recommended early contact with the patient’s primary care provider at the time of discharge by specialist services. Information
© 2015 Wiley Publishing Asia Pty Ltd
158
should be provided about the treatment and follow-up plans as well as the management of adverse events how and when to access specialist support.20 Studies have investigated a number of methods of transferring information, such as the use of patient-held records,21 case conferencing,16 faxed treatment regimes,22 structured information packs23 and use of electronic health records.24 Despite reports that such programs result in numerous benefits – including improved sharing of information, increased collaboration, GPs being better equipped to provide care, more coordinated care and higher GP satisfaction with the secondary provider – there has not been universal uptake due to the lack of a systematic processes for embedding them into routine practice at an institutional level and across health jurisdictions. Frequently, the success of projects is dependent on the interpersonal and communication skills of individuals involved, rather than a process being systematically implemented.25 E-health initiatives have been identified as an approach that will potentially improve many of the identified concerns about communication between health professionals and across institutions.26 However, implementation of such programs has been hampered by concerns relating to e-health’s effects on the roles and responsibilities of health professionals, management of risks associated with its use, transparency in its use27,28 and the costeffectiveness of such programs.29 Nevertheless, locally implemented e-health programs have resulted in improved access to information about patients’ treatment regimes and follow-up requirements for GPs. While attempts to embed e-health programs across jurisdictions, such as the Australian Personally Controlled Electronic Health Records for All Australians initiative, are slow to be implemented and are hampered by limited consumer use,30 it is anticipated that they will contribute to more effective information sharing and facilitate greater primary sector involvement in the management of people diagnosed with cancer. There are a number of limitations that may affect the generalizability of our study. Our response rate for the national survey (33%) was lower than expected, and although our sample size was large enough to ascertain differences between all participants, the number of participants who commented on issues pertaining to communication was relatively small. As outlined elsewhere, our sample is representative of all Australian GPs in terms of geographical location, and similar in terms of age and hours worked per week.10 However, participants who provided open comments about communication issues worked fewer hours, and were more likely to
© 2015 Wiley Publishing Asia Pty Ltd
N Lizama et al.
be female and working in nonmetropolitan areas. It is also possible that GPs who were frustrated with the quality of communication they received from specialists and hospitals were more likely to include comments that described negative experiences or feeling undervalued. Hence, open comments may not be representative of all GPs, but nonetheless reflect the frustrations of GPs for whom communication is particularly important, such as those from nonmetropolitan areas and those who are more interested in cancer care. A further limitation is that our research was limited to the comments that participants included in the survey, so we were unable to explore participants’ views in greater depth; as such, our analysis may be less comprehensive and complex than if we had undertaken participant interviews. However, despite these limitations, our study provides important information about GPs’ experiences of communication when delivering cancer care.
CONCLUSION Timely information sharing and communication, as well as development of collaborative interprofessional relationships, is important to engage GPs in cancer care – especially GPs who have a higher level of interest in helping to provide care for people diagnosed with cancer.
ACKNOWLEDGMENTS We would like to express our appreciation to the Australian general practitioners who completed the Preferences for Managing Patients Diagnosed with Cancer questionnaire and who made further comments about their experiences. This research was funded by the Cancer and Palliative Care Research and Evaluation Unit (CaPCREU), which is a collaboration between Curtin University, Edith Cowan University and The University of Western Australia. CaPCREU was established with funding from the Western Australian Government Department of Health through the WA Cancer and Palliative Care Network. The views expressed in this paper are not necessarily those of the WA Cancer and Palliative Care Network.
REFERENCES 1 Australian Institute of Health and Welfare. Older Australia at a Glance. Canberra: Australian Institute of Health and Welfare, Australian Government Department of Health and Ageing, 2002.
Asia-Pac J Clin Oncol 2015; 11: 152–159
Keeping primary care “in the loop”
2 National Health and Hospitals Reform Commission. A Healthier Future for All Australians – Final Report of the National Health and Hospitals Reform Commission. Canberra, 2009; 107. 3 Weller DP, Harris MF. Cancer care: what role for the general practitioner? Med J Aust 2008; 189: 59–60. 4 McAvoy B. General practitioners and cancer control. Med J Aust 2007; 187: 115–7. 5 Grunfeld E, Mant D, Yudkin P et al. Routine follow-up of breast cancer in primary care: randomised trial. Br Med J 1996; 313: 665–9. 6 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 2006; 24: 848–55. 7 Mahboubi A, Lejeune C, Coriat R et al. Which patients with colorectal cancer are followed up by general practitioners? A population-based study. Eur J Cancer Prev 2007; 16: 535–41. 8 Wattchow D, Weller D, Esterman A et al. General practice versus surgical-based follow-up for patients with colon cancer: randomised controlled trial. Br J Cancer 2006; 94: 1116–21. 9 Hanks H, Veitch P, Harris M. A rural/urban comparison of the roles of the general practitioner in colorectal cancer management. Aust J Rural Health 2008; 16: 376–82. 10 Johnson CE, Lizama N, Garg N, Ghosh M, Emery J, Saunders C. Australian general practitioners’ preferences for managing the care of people diagnosed with cancer. Asia Pac J Clin Oncol 2014; 10: e90–8. 11 Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs 2008; 62: 107–15. 12 Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005; 15: 1277–88. 13 McConnell D, Butow PN, Tattersall MHN. Improving the letters we write: an exploration of doctor-doctor communication in cancer care. Br J Cancer 1999; 80: 427–37. 14 O’Malley AS, Reschovsky JD. Referral and consultation communication between primary care and specialist physicians: finding common ground. Arch Intern Med 2011; 171: 56–65. 15 Nazareth I, Jones L, Irving A et al. Perceived concepts of continuity of care in people with colorectal and breast cancer – a qualitative case study analysis. Eur J Cancer Care (Engl) 2008; 17: 569–77. 16 Mitchell G, Cherry M, Kennedy R et al. General practitioner, specialist providers case conferences in palliative care. Aust Fam Physician 2005; 34: 389–92. 17 Lewis RA, Neal RD, Williams NH et al. Follow-up of cancer in primary care versus secondary care: systematic review. Br J Gen Pract 2009; 59: e234–47.
Asia-Pac J Clin Oncol 2015; 11: 152–159
159
18 Shipman C, Addington-Hall J, Barclay S et al. How and why do GPs use specialist palliative care services? Palliat Med 2002; 16: 241–6. 19 Smith S, Allwright S, O’Dowd T. Effectiveness of shared care across the interface between primary and specialty care in chronic disease management (Review). Cochrane Database Syst Rev 2009; 18: CD004910. 20 Emery J, Trevena L, Mazza D et al. The role of primary and community-based healthcare professionals in early detection and follow-up in cancer care – a rapid review of best practice models. Evidence Check rapid review Sax Institute, Cancer Institute NSW, Primary Care Collaborative Cancer Clinical Trials Group, 2012. 21 Gysels M, Richardson A, Higginson IJ. Does the patientheld record improve continuity and related outcomes in cancer care: a systematic review. Health Expect 2007; 10: 75–91. 22 Jefford M, Baravelli C, Dudgeon P et al. Tailored chemotherapy information faxed to general practitioners improves confidence in managing adverse effects and satisfaction with shared care: results from a randomized controlled trial. J Clin Oncol 2008; 26: 2272–7. 23 Kousgaard KR, Nielsen JD, Olesen F, Jensen AB. General practitioner assessment of structured oncological information accompanying newly referred cancer patients. Scand J Prim Health Care 2003; 21: 110–4. 24 Schoen C, Osborn R, Squires D et al. A survey of primary care doctors in ten countries shows progress in use of health information technology, less in other areas. Health Aff 2012; 31: 2805–16. 25 Gardiner C, Gott M, Ingleton C. Factors supporting good partnership working between generalist and specialist palliative care services: a systematic review. Br J Gen Pract 2012; 62: e353–62. 26 Sada YH, Street RL Jr, Singh H, Shada RE, Naik AD. Primary care and communication in shared cancer care: a qualitative study. Am J Manag Care 2011; 17: 259–65. 27 Fontaine P, Ross SE, Zink T, Schilling LM. Systematic review of health information exchange in primary care practices. J Am Board Fam Med 2010; 23: 655–70. 28 Mair FS, May C, O’Donnell C, Finch T, Sullivan F, Murray E. Factors that promote or inhibit the implementation of e-health systems: an explanatory systematic review. Bull World Health Organ 2012; 90: 357–64. 29 Black AD, Car J, Pagliari C et al. The impact of ehealth on the quality and safety of health care: a systematic overview. PLoS Med 2011; 8: e1000387. 30 National E-Health Transition Authority. NEHTA Scorecard August 2013. [Cited 10/08/2014.] Available from URL: http://www.nehta.gov.au/media-centre/news/445nehta-ehealth-scorecard, 2013.
© 2015 Wiley Publishing Asia Pty Ltd
