Management of cases that might benefit from radiotherapy: a standardised patient study in primary care

What is access to radiation therapy? A conceptual framework and review of influencing factors

OBJECTIVES

Optimal radiation therapy (RT) utilisation rates (RURs) have been defined for various cancer indications through extensive work in Australia and overseas. These benchmarks remain unrealised. The gap between optimal RUR and actual RUR has been attributed to inadequacies in 'RT access'. We aimed to develop a conceptual framework for the consideration of 'RT access' by examining the literature for existing constructs and translating it to the context of RT services. We further aimed to use this framework to identify and examine factors influencing 'RT access'.

METHODS

Existing models of health care access were reviewed and used to develop a multi-dimensional conceptual framework for 'RT access'. A review of the literature was then conducted to identify factors reported to affect RT access and utilisation. The electronic databases searched, the host platform and date range of the databases searched were Ovid MEDLINE, 1946 to October 2014 and PsycINFO via OvidSP,1806 to October 2014.

RESULTS

The framework developed demonstrates that 'RT access' encompasses opportunity for RT as well as the translation of this opportunity to RT utilisation. Opportunity for RT includes availability, affordability, adequacy (quality) and acceptability of RT services. Several factors at the consumer, referrer and RT service levels affect the translation of this opportunity for RT to actual RT utilisation.

CONCLUSION

'Access' is a term that is widely used in the context of health service related research, planning and political discussions. It is a multi-faceted concept with many descriptions. We propose a conceptual framework for the consideration of 'RT access' so that factors affecting RT access and utilisation may be identified and examined. Understanding these factors, and quantifying them where possible, will allow objective evaluation of their impact on RT utilisation and guide implementation of strategies to modify their effects.

Physician Associate and General Practitioner Consultations: A Comparative Observational Video Study

Background

Physician associates, known internationally as physician assistants, are a mid-level practitioner, well established in the United States of America but new to the United Kingdom. A small number work in primary care under the supervision of general practitioners, where they most commonly see patients requesting same day appointments for new problems. As an adjunct to larger study, we investigated the quality of the patient consultation of physician associates in comparison to that of general practitioners.

Method

We conducted a comparative observational study using video recordings of consultations by volunteer physician associates and general practitioners with consenting patients in single surgery sessions. Recordings were assessed by experienced general practitioners, blinded to the type of the consulting practitioner, using the Leicester Assessment Package. Assessors were asked to comment on the safety of the recorded consultations and to attempt to identify the type of practitioner. Ratings were compared across practitioner type, alongside the number of presenting complaints discussed in each consultation and the number of these which were acute, minor, or regarding a chronic condition.

Results

We assessed 62 consultations (41 general practitioner and 21 physician associates) from five general practitioners and four physician associates. All consultations were assessed as safe; but general practitioners were rated higher than PAs in all elements of consultation. The general practitioners were more likely than physician associates to see people with multiple presenting complaints (p<0.0001) and with chronic disease related complaints (p = 0.008). Assessors correctly identified general practitioner consultations but not physician associates. The Leicester Assessment Package had limited inter-rater and intra-rater reliability.

Conclusions

The physician associate consultations were with a less complex patient group. They were judged as competent and safe, although general practitioner consultations, unsurprisingly, were rated as more competent. Physician associates offer a complementary addition to the medical workforce in general practice.

Barriers to radiotherapy utilisation in New South Wales Australia: Health professionals' perceptions of impacting factors

INTRODUCTION

Utilisation of radiation therapy (RT) in Australia is below recommended evidence-based benchmarks. Barriers to the referral of patients for RT and the uptake of RT by patients may be affecting RT utilisation. The current study aimed to examine health professionals' (HPs) perceptions of potential barriers to RT referral and uptake.

METHODS

A custom survey was developed to assess perceptions regarding the degree to which a range of issues affect decisions regarding RT. Hard copy surveys were disseminated to HPs involved in the care of cancer patients across New South Wales (NSW): medical, radiation and surgical oncologists, physicians (including palliative care), and general practitioners with an interest in oncology. Electronic versions of the survey were disseminated via oncology multidisciplinary teams and professional networks at participating hospitals.

RESULTS

Two hundred fifty-three HPs participated via hard copy (n = 208) or electronic (n = 45) surveys. Two-thirds of HPs perceived acute side effects of RT, their management and impact on daily commitments, as well as fear and anxiety about RT, to exert moderate to significant influence on RT decisions. Treatment-related travel, need for accommodation and relocation were also perceived by 64% of HPs to do the same. Over half of HPs rated concern regarding late effects of RT, disruption to family and work life, and the ability to organise family and work commitments around RT, as moderate to significant influences on RT uptake.

CONCLUSION

Perceptions of HPs in NSW reveal potential important influencers of RT decisions by patients and clinicians. An understanding of these additional issues and their actual impact on RT-related decisions may inform future interventions to improve RT access and utilisation.

Rating general practitioner consultation performance in cancer care: does the specialty of assessors matter? A simulated patient study

Background

Patients treated for prostate cancer may present to general practitioners (GPs) for treatment follow up, but may be reticent to have their consultations recorded. Therefore the use of simulated patients allows practitioner consultations to be rated. The aim of this study was to determine whether the speciality of the assessor has an impact on how GP consultation performance is rated.

Methods

Six pairs of scenarios were developed for professional actors in two series of consultations by GPs. The scenarios included: chronic radiation proctitis, Prostate Specific Antigen (PSA) ‘bounce’, recurrence of cancer, urethral stricture, erectile dysfunction and depression or anxiety. Participating GPs were furnished with the patient’s past medical history, current medication, prostate cancer details and treatment, details of physical examinations. Consultations were video recorded and assessed for quality by two sets of assessors- a team of two GPs and two Radiation Oncologists deploying the Leicester Assessment Package (LAP). LAP scores by the GPs and Radiation Oncologists were compared.

Results

Eight GPs participated. In Series 1 the range of LAP scores by GP assessors was 61%-80%, and 67%-86% for Radiation Oncologist assessors. The range for GP LAP scores in Series 2 was 51%- 82%, and 56%-89% for Radiation Oncologist assessors. Within GP assessor correlations for LAP scores were 0.31 and 0.87 in Series 1 and 2 respectively. Within Radiation Oncologist assessor correlations were 0.50 and 0.72 in Series 1 and 2 respectively. Radiation Oncologist and GP assessor scores were significantly different for 4 doctors and for some scenarios. Anticipatory care was the only domain where GPs scored participants higher than Radiation Oncologist assessors.

Conclusion

The assessment of GP consultation performance is not consistent across assessors from different disciplines even when they deploy the same assessment tool.

Patients' perspectives on the role of their general practitioner after receiving an advanced cancer diagnosis

The aim of this study was to explore patients' perspectives on the role of their general practitioner (GP) after an advanced cancer diagnosis. A qualitative research approach was used. Semi-structured interviews were conducted and data were analysed using a constant comparative methodology. Participants were eligible if they were diagnosed with advanced cancer and referred for palliative radiotherapy. Data saturation was achieved after 21 interviews. Key themes included (1) obtaining diagnosis and referral for advanced cancer treatment; (2) preference for specialist oncology care; (3) a preference for GP to act as an advocate; and (4) obtaining ongoing routine care from their GP. GP involvement in the patients' management was dependent on: time since diagnosis, GP's involvement in diagnosis and referral, doctor/patient relationship, additional chronic conditions requiring management, frequency of seeing oncologist and specialist recommendation to involve GP. Patients want GPs to have varying levels of involvement following an advanced cancer diagnosis. Not all communication between GPs and patients was positive suggesting communication skills training may be a priority. Patients wished to maintain continunity of care for their non-cancer related issues and healthcare of their family members. Future research needs to focus on working with GPs to increase their role in the management of advanced cancer.

Investigating the contribution of physician assistants to primary care in England: a mixed-methods study

Background

Primary health care is changing as it responds to demographic shifts, technological changes and fiscal constraints. This, and predicted pressures on medical and nursing workforces, raises questions about staffing configurations. Physician assistants (PAs) are mid-level practitioners, trained in a medical model over 2 years at postgraduate level to work under a supervising doctor. A small number of general practices in England have employed PAs.

Objective

To investigate the contribution of PAs to the delivery of patient care in primary care services in England.

Design

A mixed-methods study conducted at macro, meso and micro organisational levels in two phases: (1) a rapid review, a scoping survey of key national and regional informants, a policy review, and a survey of PAs and (2) comparative case studies in 12 general practices (six employing PAs). The latter incorporated clinical record reviews, a patient satisfaction survey, video observations of consultations and interviews with patients and professionals.

Results

The rapid review found 49 published studies, mainly from the USA, which showed increased numbers of PAs in general practice settings but weak evidence for impact on processes and patient outcomes. The scoping survey found mainly positive or neutral views about PAs, but there was no mention of their role in workforce policy and planning documents. The survey of PAs in primary care (n = 16) found that they were mainly deployed to provide same-day appointments. The comparative case studies found that physician assistants were consulted by a wide range of patients, but these patients tended to be younger, with less medically acute or complex problems than those consulting general practitioners (GPs). Patients reported high levels of satisfaction with both PAs and GPs. The majority were willing or very willing to consult a PA again but wanted choice in which type of professional they consulted. There was no significant difference between PAs and GPs in the primary outcome of patient reconsultation for the same problem within 2 weeks, investigations/tests ordered, referrals to secondary care or prescriptions issued. GPs, blinded to the type of clinician, judged the documented activities in the initial consultation of patients who reconsulted for the same problem to be appropriate in 80% (n = 223) PA and 50% (n = 252) GP records. PAs were judged to be competent and safe from observed consultations. The average consultation with a physician assistant is significantly longer than that with a GP: 5.8 minutes for patients of average age for this sample (38 years). Costs per consultation were £34.36 for GPs and £28.14 for PAs. Costs could not be apportioned to GPs for interruptions, supervision or training of PAs.

Conclusions

PAs were found to be acceptable, effective and efficient in complementing the work of GPs. PAs can provide a flexible addition to the primary care workforce. They offer another labour pool to consider in health professional workforce and education planning at local, regional and national levels. However, in order to maximise the contribution of PAs in primary care settings, consideration needs to be given to the appropriate level of regulation and the potential for authority to prescribe medicines. Future research is required to investigate the contribution of PAs to other first contact services as well as secondary services; the contribution and impact of all types of mid-level practitioners (including nurse practitioners) in first contact services; the factors and influences on general practitioner and practice manager decision-making as to staffing and skill mix; and the reliability and validity of classification systems for both primary care patients and their presenting condition and their consequences for health resource utilisation.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Supporting patients treated for prostate cancer: a video vignette study with an email-based educational program in general practice

Background

Men who have been treated for prostate cancer in Australia can consult their general practitioner (GP) for advice about symptoms or side effects at any time following treatment. However, there is no evidence that such men are consistently advised by GPs and patients experience substantial unmet need for reassurance and advice.

Objective

The intent of the study was to evaluate a brief, email-based educational program for GPs to manage standardized patients presenting with symptoms or side effects months or years after prostate cancer treatment.

Methods

GPs viewed six pairs of video vignettes of actor-patients depicting men who had been treated for prostate cancer. The actor-patients presented problems that were attributable to the treatment of cancer. In Phase 1, GPs indicated their diagnosis and stated if they would prescribe, refer, or order tests based on that diagnosis. These responses were compared to the management decisions for those vignettes as recommended by a team of experts in prostate cancer. After Phase 1, all the GPs were invited to participate in an email-based education program (Spaced Education) focused on prostate cancer. Participants received feedback and could compare their progress and their performance with other participants in the study. In Phase 2, all GPs, regardless of whether they had completed the program, were invited to view another set of six video vignettes with men presenting similar problems to Phase 1. They again offered a diagnosis and stated if they would prescribe, refer, or order tests based on that diagnosis.

Results

In total, 64 general practitioners participated in the project, 57 GPs participated in Phase 1, and 45 in Phase 2. The Phase 1 education program was completed by 38 of the 57 (59%) participants. There were no significant differences in demographics between those who completed the program and those who did not. Factors determining whether management of cases was consistent with expert opinion were number of sessions worked per week (OR 0.78, 95% CI 0.67-0.90), site of clinical practice (remote practice, OR 2.25, 95% CI 1.01-5.03), number of patients seen per week (150 patients or more per week, OR 10.66, 95% CI 3.40-33.48), and type of case viewed. Completion of the Spaced Education did impact whether patient management was consistent with expert opinion (not completed, OR 0.88, 95% CI 0.5-1.56).

Conclusions

The management of standardized patients by GPs was particularly unlikely to be consistent with expert opinion in the management of impotence and bony metastasis. There was no evidence from this standardized patient study that Spaced Education had an impact on the management of patients in this context. However, the program was not completed by all participants. Practitioners with a greater clinical load were more likely to manage cases as per expert opinion.

The health of women treated for breast cancer: A challenge in primary care

At least one in a hundred consultations in general practice in Australia involves women being treated for breast cancer. The challenges presented during these consultations test the quality of primary care. Firstly, women are reported to prefer to discuss their breast cancer-related problems with a specialist even though research suggests that patients generally prefer to consult with a general practitioner (GP). The extent to which these patients will have maintained or return to their previous level of functioning will be a reflection on the quality of primary care, as some breast cancer-related health issues may persist beyond the time period when they are undergoing specialist review. Further, psychosocial matters, sexuality and relationships may require repeated review and perhaps consultations involving family members and would therefore be better addressed by a GP. An increasingly urgent need exists to review how best to support people who are successfully treated for life limiting illnesses, such as breast cancer.