Patients' experiences with continuum of care across hospitals:A multilevel analysis of Consumer Quality Index Continuum of Care

Objective: Communication between professionals is essential because it contributes to an optimal continuum of care. Whether patients experience adequate continuum of care is uncertain. To address this, a questionnaire was developed to elucidate this care process from a patients' perspective. In this study, the instrument's ability to measure differences in "Consumer Quality Index Continuum of Care" scores between hospitals was investigated. Methods: The questionnaire was mailed to a random sample of 2159 patients and comprised of 22 items divided over four domains, GP approach, GP referral, specialist and collaboration. Multilevel analysis was conducted to identify case-mix and determine this questionnaire's ability to measure differences in domain scores between hospitals. Results: Based on a 65% response rate, 1404 questionnaires were available for analysis. Case-mix of patient characteristics across hospitals could not be demonstrated. Some differences in scores between hospitals were observed. At most two in eight hospitals showed different domain scores. Conclusion: The ability of this questionnaire to measure differences in continuum of care scores between hospitals is limited. The outcome of this survey suggests that hospitals provide a similar level of continuum of care from a patient's perspective. Practical implications: This questionnaire is especially useful for measuring differences between patients. (C) 2010 Elsevier Ireland Ltd. All rights reserved

Follow-up of curatively treated cancer in primary care:a qualitative study of the views of Dutch GPs

BACKGROUND: Follow-up for cancer typically occurs in secondary care, and improved survival has increased demands on these services. Other care models may alleviate this burden, such as moving (parts of) follow-up care for curatively treated patients from secondary to primary care (care substitution). AIM: To explore the opinions of GPs regarding the potential benefits, barriers, and requirements of care substitution for breast and colorectal cancer. DESIGN AND SETTING: A qualitative study of the opinions of purposively sampled GPs in Dutch primary care. METHOD: Focus group sessions and individual semi-structured interviews were recorded and transcribed verbatim. Data were analysed by two independent researchers using thematic analysis. RESULTS: Two focus groups (n = 14) were conducted followed by nine individual interviews. Three main themes were identified: perceived benefits, perceived barriers, and perceived requirements. Perceived benefits included better accessibility and continuity of care, and care closer to patients' homes. Uncertainty about cancer-related competences and practical objections were perceived as barriers. Requirements included close specialist collaboration, support from patients for this change, and stepwise implementation to avoid loss of existing care quality. CONCLUSION: Most GPs reported that they were not in favour of complete care substitution, but that primary care could have greater formal involvement in oncological follow-up if there is close collaboration with secondary care (that is, shared care), support from patients, sufficient resource allocation, stepwise implementation with clear guidelines, and monitoring of quality. Clear and broadly supported protocols need to be developed and tested before implementing follow-up in primary care

Long-term psychological distress in breast cancer survivors and their matched controls:A cross-sectional study

Introduction: Breast cancer survivors often experience psychological distress shortly after diagnosis. Long-term psychological effects, however, have not been clearly demonstrated. Methods: This cross-sectional cohort study included 350 breast cancer survivors and 350 age-matched and general-practitioner-matched women. The median follow-up was 10 years. Using logistic regression we compared breast cancer survivors with controls on having (severe) symptoms of depression and/or anxiety, as measured with the Hospital Anxiety and Depression Scale. In multivariable logistic regression, we adjusted the results for a history of depression or prescription of antidepressants. Results: Larger proportions of breast cancer survivors experienced symptoms of depression (10.6%) compared with controls (4.9%) and symptoms of anxiety (18.6%) compared with controls (16.3%). The odds of symptoms of depression (OR 2.3, 95%CI 1.3-4.2), severe symptoms of depression (OR 3.3, 95%CI 1.1-10.3) and severe symptoms of anxiety (OR 2.1, 95%CI, 1.1-4.0) were significantly higher for breast cancer survivors than for controls, even after adjusting for history of depression or prescription of antidepressants. No significant difference was seen for mild symptoms of anxiety. Conclusions: Breast cancer survivors have an increased risk of symptoms of depression, including severe symptoms, and severe symptoms of anxiety compared with controls, for up to at least 10 years after diagnosis

Increased primary health care use in the first year after colorectal cancer diagnosis

OBJECTIVE: The view that the general practitioner (GP) should be more involved during the curative treatment of cancer is gaining support. This study aimed to assess the current role of the GP during treatment of patients with colorectal cancer (CRC). DESIGN: Historical prospective study, using primary care data from two cohorts. SETTING: Registration Network Groningen (RNG) consisting of 18 GPs in three group practices with a dynamic population of about 30,000 patients. SUBJECTS: Patients who underwent curative treatment for CRC (n = 124) and matched primary care patients without CRC (reference population; n = 358). MAIN OUTCOME MEASURES: Primary healthcare use in the period 1998-2009. FINDINGS: Patients with CRC had higher primary healthcare use in the year after diagnosis compared with the reference population. After correction for age, gender, and consultation behaviour, CRC patients had 54% (range 23-92%) more face-to-face contacts, 68% (range 36-108%) more drug prescriptions, and 35% (range -4-90%) more referrals compared with reference patients. Patients consulted their GP more often for reasons related to anaemia, abdominal pain, constipation, skin problems, and urinary infections. GPs also prescribed more acid reflux drugs, laxatives, anti-anaemic preparations, analgesics, and psycholeptics for CRC patients. CONCLUSIONS: The GP plays a significant role in the year after CRC diagnosis. This role may be associated with treatment-related side effects and psychological problems. Formal guidelines on the involvement of the GP during CRC treatment might ensure more effective allocation and communication of care between primary and secondary healthcare services

Adherence and Concordance between Serious Illness Care Planning Conversations and Oncology Clinician Documentation among Patients with Advanced Cancer

Background:Serious illness conversations are part of advance care planning (ACP) and focus on prognosis, values, and goals in patients who are seriously ill. To be maximally effective, such conversations must be documented accurately and be easily accessible. Objectives:The two coprimary objectives of the study were to assess concordance between written documentation and recorded audiotaped conversations, and to evaluate adherence to the Serious Illness Conversation Guide questions. Methods:Data were obtained as part of a trial in patients with advanced cancer. Clinicians were trained to use a guide to conduct and document serious illness conversations. Conversations were audiotaped. Two researchers independently compared audiorecordings with the corresponding documentation in an electronic health record (EHR) template and free-text progress notes, and rated the degree of concordance and adherence. Results:We reviewed a total of 25 audiorecordings. Clinicians addressed 87% of the conversation guide elements. Prognosis was discussed least frequently, only in 55% of the patients who wanted that information. Documentation was fully concordant with the conversation 43% of the time. Concordance was best when documenting family matters and goals, and least frequently concordant when documenting prognostic communication. Most conversations (64%) were documented in the template, a minority (28%) only in progress notes and two conversations (8%) were not documented. Concordance was better when the template was used (62% vs. 28%). Conclusion:Clinicians adhered well to the conversation guide. However, key information elicited was documented and fully concordant less than half the time. Greater concordance was observed when clinicians used a prespecified template. The combined use of a guide and EHR template holds promise for ACP conversations

Diagnostic accuracy of follow-up tests for detecting colorectal cancer recurrences in primary care:A systematic review and meta-analysis

Introduction Traditionally, follow-up of colorectal cancer (CRC) is performed in secondary care. In new models of care, the screening part care could be replaced to primary care. We aimed to synthesise evidence on the diagnostic accuracy of commonly used screeners in CRC follow-up applicable in primary care: carcinoembryonic antigen (CEA), ultrasound and physical examination. Methods Medline, EMBASE, Cochrane Trial Register and Web of Science databases were systematically searched. Studies were included if they provided sufficient data for a 2 × 2 contingency tables. QUADAS-2 was used to assess methodological quality. We performed bivariate random effects meta-analysis, generated a hypothetical cohort, and reported sensitivity and specificity. Results We included 12 studies (n = 3223, median recurrence rate 19.6%). Pooled estimates showed a sensitivity for CEA (≤ 5 μg/l) of 59% [47%–70%] and a specificity of 89% [80%–95%]. Only few studies reported sensitivities and specificities for ultrasound (36–70% and 97–100%, respectively) and clinical examination (23% and 27%, respectively). Conclusion In practice, GPs could perform CEA screening. Radiological examination in a hospital setting should remain part of the surveillance strategy. Personalised algorithms accounting for recurrence risk and changes of CEA-values over time might add to the diagnostic value of CEA in primary care

A Qualitative Study of Serious Illness Conversations in Patients with Advanced Cancer

BACKGROUND: Conversations with seriously ill patients about their values and goals have been associated with reduced distress, a better quality of life, and goal-concordant care near the end of life. Yet, little is known about how such conversations are conducted. OBJECTIVE: To characterize the content of serious illness conversations and identify opportunities for improvement. DESIGN: Qualitative analysis of audio-recorded, serious illness conversations using an evidence-based guide and obtained through a cluster randomized controlled trial in an outpatient oncology setting. Setting/Measurements: Clinicians assigned to the intervention arm received training to use the "Serious Illness Conversation Guide" to have a serious illness conversation about values and goals with advanced cancer patients. Conversations were de-identified, transcribed verbatim, and independently coded by two researchers. Key themes were analyzed. RESULTS: A total of 25 conversations conducted by 16 clinicians were evaluated. The median conversation duration was 14 minutes (range 4-37), with clinicians speaking half of the time. Thematic analyses demonstrated five key themes: (1) supportive dialogue between patients and clinicians; (2) patients' openness to discuss emotionally challenging topics; (3) patients' willingness to articulate preferences regarding life-sustaining treatments; (4) clinicians' difficulty in responding to emotional or ambiguous patient statements; and (5) challenges in discussing prognosis. CONCLUSIONS: Data from this exploratory study suggest that seriously ill patients are open to discussing values and goals with their clinician. Yet, clinicians may struggle when disclosing a time-based prognosis and in responding to patients' emotions. Such skills should be a focus for additional training for clinicians caring for seriously ill patients

Implementation and evaluation of a physical activity counselling programme in primary care among cancer survivors:SoDA study protocol

INTRODUCTION: Physical activity (PA) favourably affects various health outcomes in cancer survivors, but little is known about how to implement a PA programme in primary care. We therefore aim to implement and evaluate such a programme for cancer survivors in general practice. METHODS AND ANALYSES: The Stimulation of Daily Activity study is an implementation study with a single-arm longitudinal design in 15 Dutch general practices. Patients aged ≥18 years who finished cancer treatment more than 6 months ago will be eligible for inclusion. The intervention will comprise six coaching sessions with the practice nurse in 9 months, seeking to increase PA in daily activities and using an activity tracker for goal setting and feedback. The Reach, Effectiveness, Adoption, Implementation and Maintenance framework will be used to evaluate implementation in terms of the health outcomes, extent of implementation and barriers and facilitators to implementation, using a mixed methods approach. Descriptive analyses and linear mixed model analyses will be performed on the quantitative data, while qualitative data from focus groups and interviews will be analysed by thematic analyses. ETHICS AND DISSEMINATION: The Medical Research Ethics Committee of the University Medical Centre Groningen, the Netherlands, concluded that this study was not subject to the Dutch Medical Research Involving Human Subjects Act (registration number: 201900586). The study results will be made available to patients and general practitioners via (inter)national publications and conferences, newsletters, public summaries and via (social) media