A randomised controlled trial to improve the role of the general practitioner in cancer rehabilitation: effect on patients' satisfaction with their general practitioners

Effects of structured involvement of the primary care team versus standard care after a cancer diagnosis on patient satisfaction and healthcare use: the GRIP randomised controlled trial

Background

The growing number of cancer survivors and treatment possibilities call for more personalised and integrated cancer care. Primary care seems well positioned to support this. We aimed to assess the effects of structured follow-up of a primary care team after a cancer diagnosis.

Methods

We performed a multicentre randomised controlled trial enrolling patients curatively treated for breast, lung, colorectal, gynaecologic cancer or melanoma. In addition to usual cancer care in the control group, patients randomized to intervention were offered a “Time Out consultation” (TOC) with the general practitioner (GP) after diagnosis, and subsequent follow-up during and after treatment by a home care oncology nurse (HON). Primary outcomes were patient satisfaction with care (questionnaire: EORTC-INPATSAT-32) and healthcare utilisation. Intention-to-treat linear mixed regression analyses were used for satisfaction with care and other continuous outcome variables. The difference in healthcare utilisation for categorical data was calculated with a Pearson Chi-Square or a Fisher exact test and count data (none versus any) with a log-binomial regression.

Results

We included 154 patients (control n = 77, intervention n = 77) who were mostly female (75%), mainly diagnosed with breast cancer (51%), and had a mean age of 61 (SD ± 11.9) years. 81% of the intervention patients had a TOC and 68% had HON contact. Satisfaction with care was high (8 out of 10) in both study groups. At 3 months after treatment, GP satisfaction was significantly lower in the intervention group on 3 of 6 subscales, i.e., quality (− 14.2 (95%CI -27.0;-1.3)), availability (− 15,9 (− 29.1;-2.6)) and information provision (− 15.2 (− 29.1;-1.4)). Patients in the intervention group visited the GP practice and the emergency department more often ((RR 1.3 (1.0;1.7) and 1.70 (1.0;2.8)), respectively).

Conclusions

In conclusion, the GRIP intervention, which was designed to involve the primary care team during and after cancer treatment, increased the number of primary healthcare contacts. However, it did not improve patient satisfaction with care and it increased emergency department visits. As the high uptake of the intervention suggests a need of patients, future research should focus on optimizing the design and implementation of the intervention.

Trial registration

GRIP is retrospectively (21/06/2016) registered in the ‘Netherlands Trial Register’ (NTR5909).

Healthcare practices that increase the quality of care in cancer trajectories from a general practice perspective: a scoping review

OBJECTIVE

General practice plays an important role in cancer trajectories, and cancer patients request the continuous involvement of general practice. The objective of this scoping review was to identify healthcare practices that increase the quality of care in cancer trajectories from a general practice perspective.

DESIGN, SETTING, AND SUBJECTS

A scoping review of the literature published in Danish or English from 2010 to 2020 was conducted. Data was collected using identified keywords and indexed terms in several databases (PubMed, MEDLINE, EBSCO CINAHL, Scopus, and ProQuest), contacting key experts, searching through reference lists, and reports from selected health political, research- and interest organizations' websites.

MAIN OUTCOME MEASURES

We identified healthcare practices in cancer trajectories that increase quality care. Identified healthcare practices were grouped into four contextual domains and allocated to defined phases in the cancer trajectory. The results are presented according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR).

RESULTS

A total of 45 peer-reviewed and six non-peer-reviewed articles and reports were included. Quality of care increases in all phases of the cancer trajectory when GPs listen carefully to the full story and use action plans. After diagnosis, quality of care increases when GPs and practice staff have a proactive care approach, act as interpreters of diagnosis, treatment options, and its consequences, and engage in care coordination with specialists in secondary care involving the patient.

CONCLUSION

This scoping review identified healthcare practices that increase the quality of care in cancer trajectories from a general practice perspective. The results support general practice in investigating own healthcare practices and identifying possibilities for quality improvement.KEY POINTSIdentified healthcare practices in general practice that increase the quality of care in cancer trajectories:Listen carefully to the full storyUse action plans and time-out-consultationsPlan and provide proactive careAct as an interpreter of diagnosis, treatment options, and its consequences for the patientCoordinate care with specialists, patients, and caregivers with mutual respectIdentified barriers for quality of care in cancer trajectories are:Time constraints in consultationsLimited accessibility for patients and caregiversHealth practices to increase the quality of care should be effective, safe, people-centered, timely, equitable, integrated, and efficient. These distinctions of quality of care, support general practice in investigating and improving quality of care in cancer trajectories.

Effects of a time out consultation with the general practitioner on cancer treatment decision-making: a randomised controlled trial: Time out with the general practitioner and cancer treatment decision

Objective

Improving shared decision‐making (SDM) enables more tailored cancer treatment decisions. We evaluated a Time Out consultation (TOC) with the general practitioner (GP), between cancer diagnosis and treatment decision, which aims at supporting SDM and improving continuity of primary care. This study aims to evaluate the effects of a TOC on perceived SDM, information provision and self‐efficacy.

Methods

This randomised controlled trial included newly diagnosed patients with curable cancer (breast, lung, colorectal, gynaecologic and melanoma) from four Dutch hospitals. Primary outcome is perceived SDM and secondary outcomes are information provision and self‐efficacy.

Results

One hundred fifty‐four patients (control n = 77, intervention n = 77) – female: 75%, mean age: 61 (SD ± 11.9). In the intervention group, 80.5% (n = 62) had a TOC, of which 82.3% (n = 51) took place after treatment decision. Perceived SDM was lower in the intervention group (−8.9 [95% CI: 0.6–17.1]). Among those with a TOC before treatment decision (n = 11), perceived SDM was comparable to the control group (66.5 ± 27.2 vs. 67.9 ± 26.1).

Conclusion

Even though patients are motivated to have a TOC, implementing a TOC between diagnosis and treatment decision is challenging. Effects of a timely TOC could not be established. Non‐timely TOC decreased perceived SDM. Planning of the TOC should be optimised, and future research should establish if adequately timed TOC results in improved SDM in cancer patients.

Cross-sectoral video consultations in cancer care: perspectives of cancer patients, oncologists and general practitioners

Purpose

Multidisciplinary video consultations are one method of improving coherence and coordination of care in cancer patients, but knowledge of user perspectives is lacking. Continuity of care is expected to have a significant impact on the quality of cancer care. Enhanced task clarification and shared responsibility between the patient, oncologist and general practitioner through video consultations might provide enhanced continuity in cancer care.

Method

We used descriptive survey data from patients and doctors in the intervention group based on a randomised controlled trial to evaluate the user perspectives and fidelity of the intervention.

Results

Patients expressed that they were able to present their concerns in 95% of the consultations, and believed it was beneficial to have both their doctors present in 84%. The general practitioner and oncologist found that tripartite video consultation would lead to better coordination of care in almost 90% of the consultations. However, the benefits of handling social issues and comorbidity were sparser. Consultations were not accomplished in 11% due to technical problems and sound and video quality were non-satisfactory in 20%.

Conclusion

Overall, multidisciplinary video consultations between cancer patient, general practitioner and oncologist were feasible in daily clinics. Initial barriers to address were technical issues and seamless planning. Patients reported high satisfaction, patient centredness and clarity of roles. General practitioners and oncologists were overall positive regarding role clarification and continuity, although less pronounced than patients.

Trial registration

www.clincialtrials.gov, NCT02716168.

Improving continuity by bringing the cancer patient, general practitioner and oncologist together in a shared video-based consultation - protocol for a randomised controlled trial

BACKGROUND

Strengthening the coordination, continuity and intersectoral cooperation for cancer patients' during cancer treatment is being underlined by international guidelines and research. General practitioners have assumed a growing role in the cancer patient disease trajectory because of their roles as coordinators and the consistent health provider. However, general practitioners are challenged in providing support for cancer patients both during treatment and in the survivorship phase. General practitioners reported barriers are lack of timely and relevant communication from the oncologist and limited knowledge to guidelines, as well as lack of trust from patients. Therefore, the current study will examine whether a shared video-based consultation between the cancer patient, general practitioner and oncologist can ease general' challenges and thereby enhance the patient-centeredness for the cancer patients and their perception of intersectoral cooperation and continuity.

METHODS

The study is designed as a pragmatic randomised controlled trial for patients starting chemotherapy at the Department of Oncology, Lillebaelt Hospital, Denmark who are listed with a general practitioner in the Region of Southern Denmark. We intend to include 278 adults diagnosed with colorectal, breast, lung, gynecologic or prostate cancer. The intervention group will receive the "Partnership intervention" which consists of one or more video-consultations between the cancer patient, general practitioner and oncologist. The consultations are estimated to last between 10 and 20 min. The specific aims of the consultation are, summary of the patient trajectory, sharing of knowledge regarding comorbidity, psychosocial resources and needs, physical well-being, medicine, anxiety and depression symptoms, spouses, workability and late complication and side-effects to the cancer treatment.

DISCUSSION

Video-based consultation that brings the cancer patient, the general practitioner and the oncologist together in the early phase of treatment may facilitate a sense of partnership that is powerful enough to improve the patient's perception of intersectoral cooperation, continuity of cancer care and health-related quality of life.

TRIAL REGISTRATION

ClincialTrials.gov Identifier: NCT02716168 . Date of registration: 03.03.2016.

Involving the general practitioner during curative cancer treatment: a systematic review of health care interventions

OBJECTIVE

The role of primary care providers (PCP) in the cancer care continuum is expanding. In the post-treatment phase, this role is increasingly recognised by policy makers and healthcare professionals. During treatment, however, the role of PCP remains largely undefined. This systematic review aims to map the content and effect of interventions aiming to actively involve the general practitioner (GP) during cancer treatment with a curative intent.

STUDY DESIGN

Systematic review.

PARTICIPANTS

Patients with cancer treated with curative intent.

DATA SOURCES

Randomised controlled trials (RCTs), controlled clinical trials (CCT), controlled before and after studies and interrupted time series focusing on interventions designed to involve the GP during curative cancer treatment were systematically identified from PubMed and EMBASE and were subsequently reviewed. Risk of bias was scored according to the Effective Practice and Organisation of Care Group risk of bias criteria.

RESULTS

Five RCTs and one CCT were included. Interventions and effects were heterogeneous across studies. Four studies implemented interventions focussing on information transfer to the GP and two RCTs implemented patient-tailored GP interventions. The studies have a low-medium risk of bias. Three studies show a low uptake of the intervention. A positive effect on patient satisfaction with care was found in three studies. Subgroup analysis suggests a reduction of healthcare use in elderly patients and reduction of clinical anxiety in those with higher mental distress. No effects are reported on patients' quality of life (QoL).

CONCLUSION

Interventions designed to actively involve the GP during curative cancer treatment are scarce and diverse. Even though uptake of interventions is low, results suggest a positive effect of GP involvement on patient satisfaction with care, but not on QoL. Additional effects for vulnerable subgroups were found. More robust evidence for tailored interventions is needed to enable the efficient and effective involvement of the GP during curative cancer treatment.

PROSPERO REGISTRATION NUMBER

CRD42018102253.

Systematic screening and assessment of psychosocial well-being and care needs of people with cancer

BACKGROUND

Receiving a diagnosis of cancer and the subsequent related treatments can have a significant impact on an individual's physical and psychosocial well-being. To ensure that cancer care addresses all aspects of well-being, systematic screening for distress and supportive care needs is recommended. Appropriate screening could help support the integration of psychosocial approaches in daily routines in order to achieve holistic cancer care and ensure that the specific care needs of people with cancer are met and that the organisation of such care is optimised.

OBJECTIVES

To examine the effectiveness and safety of screening of psychosocial well-being and care needs of people with cancer. To explore the intervention characteristics that contribute to the effectiveness of these screening interventions.

SEARCH METHODS

We searched five electronic databases in January 2018: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, and CINAHL. We also searched five trial registers and screened the contents of relevant journals, citations, and references to find published and unpublished trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and non-randomised controlled trials (NRCTs) that studied the effect of screening interventions addressing the psychosocial well-being and care needs of people with cancer compared to usual care. These screening interventions could involve self-reporting of people with a patient-reported outcome measures (PROMs) or a semi-structured interview with a screening interventionist, and comprise a solitary screening intervention or screening with guided actions. We excluded studies that evaluated screening integrated as an element in more complex interventions (e.g. therapy, coaching, full care pathways, or care programmes).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed methodological quality for each included study using the Cochrane tool for RCTs and the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool for NRCTs. Due to the high level of heterogeneity in the included studies, only three were included in meta-analysis. Results of the remaining 23 studies were analysed narratively.

MAIN RESULTS

We included 26 studies (18 RCTs and 8 NRCTs) with sample sizes of 41 to 1012 participants, involving a total of 7654 adults with cancer. Two studies included only men or women; all other studies included both sexes. For most studies people with breast, lung, head and neck, colorectal, prostate cancer, or several of these diagnoses were included; some studies included people with a broader range of cancer diagnosis. Ten studies focused on a solitary screening intervention, while the remaining 16 studies evaluated a screening intervention combined with guided actions. A broad range of intervention instruments was used, and were described by study authors as a screening of health-related quality of life (HRQoL), distress screening, needs assessment, or assessment of biopsychosocial symptoms or overall well-being. In 13 studies, the screening was a self-reported questionnaire, while in the remaining 13 studies an interventionist conducted the screening by interview or paper-pencil assessment. The interventional screenings in the studies were applied 1 to 12 times, without follow-up or from 4 weeks to 18 months after the first interventional screening. We assessed risk of bias as high for eight RCTs, low for five RCTs, and unclear for the five remaining RCTs. There were further concerns about the NRCTs (1 = critical risk study; 6 = serious risk studies; 1 = risk unclear).Due to considerable heterogeneity in several intervention and study characteristics, we have reported the results narratively for the majority of the evidence.In the narrative synthesis of all included studies, we found very low-certainty evidence for the effect of screening on HRQoL (20 studies). Of these studies, eight found beneficial effects of screening for several subdomains of HRQoL, and 10 found no effects of screening. One study found adverse effects, and the last study did not report quantitative results. We found very low-certainty evidence for the effect of screening on distress (16 studies). Of these studies, two found beneficial effects of screening, and 14 found no effects of screening. We judged the overall certainty of the evidence for the effect of screening on HRQoL to be very low. We found very low-certainty evidence for the effect of screening on care needs (seven studies). Of these studies, three found beneficial effects of screening for several subdomains of care needs, and two found no effects of screening. One study found adverse effects, and the last study did not report quantitative results. We judged the overall level of evidence for the effect of screening on HRQoL to be very low. None of the studies specifically evaluated or reported adverse effects of screening. However, three studies reported unfavourable effects of screening, including lower QoL, more unmet needs, and lower satisfaction.Three studies could be included in a meta-analysis. The meta-analysis revealed no beneficial effect of the screening intervention on people with cancer HRQoL (mean difference (MD) 1.65, 95% confidence interval (CI) -4.83 to 8.12, 2 RCTs, 6 months follow-up); distress (MD 0.0, 95% CI -0.36 to 0.36, 1 RCT, 3 months follow-up); or care needs (MD 2.32, 95% CI -7.49 to 12.14, 2 RCTs, 3 months follow-up). However, these studies all evaluated one specific screening intervention (CONNECT) in people with colorectal cancer.In the studies where some effects could be identified, no recurring relationships were found between intervention characteristics and the effectiveness of screening interventions.

AUTHORS' CONCLUSIONS

We found low-certainty evidence that does not support the effectiveness of screening of psychosocial well-being and care needs in people with cancer. Studies were heterogeneous in population, intervention, and outcome assessment.The results of this review suggest a need for more uniformity in outcomes and reporting; for the use of intervention description guidelines; for further improvement of methodological certainty in studies and for combining subjective patient-reported outcomes with objective outcomes.

French women's representations and experiences of the post-treatment management of breast cancer and their perception of the general practitioner's role in follow-up care: A qualitative study

Background

In France, the Cancer Plan II 2009‐2013 was launched to improve post‐cancer management and promote greater involvement of general practitioners (GPs) in follow‐up care.

Objectives

We investigated how women experienced the post‐treatment management of breast cancer and perceived the role of the GP in follow‐up care.

Design

We conducted a qualitative study based on semi‐structured interviews with women with breast cancer in remission. The interviews were transcribed and analysed in accordance with the principles of thematic analysis.

Setting and participants

We interviewed 21 patients aged between 30 and 86. Eighteen breast cancer survivors were recruited from GP practices and five from a patients’ association.

Results

Four themes emerged from the thematic analysis: that breast cancer is a life‐changing event; how patients managed the effects of treatment; how patients viewed the future; and patients’ expectations of their GP.

Discussion and conclusion

French survivors of breast cancer perceived the physical changes caused by their illness to impact their womanhood, leading to difficulties with sexual relations, a diminished sense of self and fears for the future. They felt abandoned at the end of treatment and desired support. They appreciated the ease of contacting their GP but considered follow‐up care outside their remit. They agreed to be followed up by their GP, provided that they co‐operated closely with a cancer specialist. This is in accordance with the French Cancer Plan II 2009‐2013, which recommends greater involvement of GPs in a monitoring protocol shared with cancer specialists.

Interventions to improve care coordination between primary healthcare and oncology care providers: a systematic review

Coordination of patient care between primary care and oncology care providers is vital to care quality and outcomes across the cancer continuum, yet it is known to be challenging. We conducted a systematic review to evaluate current or new models of care and/or interventions aimed at improving coordination between primary care and oncology care providers for patients with adult breast and/or colorectal cancer. MEDLINE, EMBASE, CINAHL, Cochrane Library Database of Systematic Reviews, and the Centre for Reviews and Dissemination were searched for existing English language studies published between January 2000 and 15 May 2015. Systematic reviews, meta-analyses, randomised controlled trials (RCTs) and non-randomised studies were included if they evaluated a specific model/intervention that was designed to improve care coordination between primary care and oncology care providers, for any stage of the cancer continuum, for patients with adult breast and/or colorectal cancer. Two reviewers extracted data and assessed risk of bias. Twenty-two studies (5 systematic reviews, 6 RCTs and 11 non-randomised studies) were included and varied with respect to the targeted phase of the cancer continuum, type of model or intervention tested, and outcome measures. The majority of studies showed no statistically significant changes in any patient, provider or system outcomes. Owing to conceptual and methodological limitations in this field, the review is unable to provide specific conclusions about the most effective or preferred model/intervention to improve care coordination. Imprecise results that lack generalisability and definitiveness provide limited evidence to base the development of future interventions and policies.

TRIAL REGISTRATION NUMBER

CRD42015025006.

What role does the general practitioner in France play among cancer patients during the initial treatment phase with intravenous chemotherapy? A qualitative study

BACKGROUND

France's ethical and legal principles place general practitioners (GPs) at the forefront of cancer patient management, coordination, and follow-up. The objective of this study was to determine the actual role of GPs in the follow-up phase as well as patient perspectives on their GPs.

METHOD

A multidisciplinary group of researchers conducted this qualitative study based on in-depth interviews of 50 patients managed at two cancer centres. A content analysis method was used to analyse the study data.

RESULTS

According to the patients interviewed for this study, their GPs were relatively ineffective at managing medical problems related to cancer by comparison with their oncologists. Nonetheless, the patients had all consulted their GPs during the interval between the diagnosis and our interview. Reasons given for consulting their GPs included administrative matters, psychological support, reassurance, and advice, but also to a lesser extent, medical management.

CONCLUSION

Patients' perspectives called attention to two aspects of the role of GPs in the French healthcare system: (a) the importance of GPs within an effective system for managing cancer patients, and (b) for some patients, GPs' relative lack of medical skill compared to oncologists.