Oncologists' perspectives on post-cancer treatment communication and care coordination with primary care physicians.

Post-treatment cancer care is often fragmented and of suboptimal quality. We explored factors that may affect cancer survivors' post-treatment care coordination, including oncologists' use of electronic technologies such as e-mail and integrated electronic health records (EHRs) to communicate with primary care physicians (PCPs). We used data from a survey (357 respondents; participation rate 52.9%) conducted in 2012-2013 among medical oncologists caring for patients in a large US study of cancer care delivery and outcomes. Oncologists reported their frequency and mode of communication with PCPs, and role in providing post-treatment care. Seventy-five per cent said that they directly communicated with PCPs about post-treatment status and care recommendations for all/most patients. Among those directly communicating with PCPs, 70% always/usually used written correspondence, while 36% always/usually used integrated EHRs; telephone and e-mail were less used. Eighty per cent reported co-managing with PCPs at least one post-treatment general medical care need. In multivariate-adjusted analyses, neither communication mode nor intensity were associated with co-managing survivors' care. Oncologists' reliance on written correspondence to communicate with PCPs may be a barrier to care coordination. We discuss new research directions for enhancing communication and care coordination between oncologists and PCPs, and to better meet the needs of cancer survivors post-treatment.

Surgical treatment of early stage breast cancer in elderly: an international comparison.

Over 40% of breast cancer patients are diagnosed above the age of 65. Treatment of these elderly patients will probably vary over countries. The aim of this study was to make an international comparison (several European countries and the US) of surgical and radiation treatment for elderly women with early stage breast cancer. Survival comparisons were also made. Data were obtained from national or regional population-based registries in the Netherlands, Switzerland, Ireland, Belgium, Germany, and Portugal. For the US patients were selected from the Surveillance, Epidemiology, and End Results (SEER) database. Early stage breast cancer patients aged ≥ 65 diagnosed between 1995 and 2005 were included. An international comparison was made for breast and axillary surgery, radiotherapy after breast conserving surgery (BCS), and relative or cause-specific survival. Overall, 204.885 patients were included. The proportion of patients not receiving any surgery increased with age in many countries; however, differences between countries were large. In most countries more than half of all elderly patients received breast conserving surgery (BCS), with the highest percentage in Switzerland. The proportion of elderly patients that received radiotherapy after BCS decreased with age in all countries. Moreover, in all countries the proportion of patients who do not receive axillary surgery increased with age. No large differences in survival between countries were recorded. International comparisons of surgical treatment for elderly women with early stage breast cancer are scarce. This study showed large international differences in treatment of elderly early stage breast cancer patients, with the most striking result the large proportion of elderly who did not undergo surgery at all. Despite large treatment differences, survival does not seem to be affected in a major way.

Discussion of treatment options for early-stage breast cancer: effect of provider specialty on type of surgery and satisfaction.

OBJECTIVES: To describe the physicians with whom breast cancer patients discuss treatment options and assess whether discussing surgical options with a medical oncologist is associated with type of surgery and satisfaction. RESEARCH DESIGN: Medical record abstraction and survey. SUBJECTS: Women with early-stage breast cancer numbering 2,426 in two states-Massachusetts, where the rate of breast-conserving surgery is high, and Minnesota, where it is lower. MEASURES: Receipt of breast-conserving surgery and satisfaction. RESULTS: Women in Massachusetts discussed breast cancer treatments with more physicians than women in Minnesota (mean 3.5 vs. 2.8; P <0.001) and more often discussed surgical options with a medical oncologist (52% vs. 28%; P <0.001). Using propensity score analyses, in Massachusetts, discussing surgical options with a medical oncologist was not related to type of surgery (adjusted difference in rate of breast-conserving surgery: 3.9%, 95% CI -3.6% to 11.5%) but was associated with greater satisfaction (adjusted difference: 8.1, 95% CI 2.0% to 14.2%). In Minnesota, discussing surgical options with a medical oncologist was associated with breast-conserving surgery (adjusted difference: 12.6%, 95% CI 5.6% to 19.7%) with no difference in satisfaction (adjusted difference: -1.5%, 95% CI -6.8% to 3.8%). CONCLUSIONS: Outcomes associated with discussing surgical treatments with a medical oncologist vary with local care patterns. Where breast-conserving surgery is standard care, seeing a medical oncologist is not related to type of surgery, but is associated with greater satisfaction. Where it is not the standard, seeing a medical oncologist is associated with more breast-conserving surgery and equivalent satisfaction. These findings suggest that collaborative care may benefit women with respect to treatment selection or satisfaction.

Assessing the relationship between quality of care and the characteristics of health care organizations.

In the past two decades, relationships among health plans, medical groups, and providers have grown more complex and the number of clinical management strategies has increased. In this context, determining the independent effect of a particular organizational strategy on quality of care has become more difficult. The authors review some of the issues a researcher must address when studying the relationship between organizational characteristics and quality of care. They offer criteria for selecting a research question, list organizational characteristics that may influence quality, and suggest sampling and study design techniques to reduce confounding. Since this type of research often requires a health care organization as collaborator, the authors discuss strategies for developing research partnerships and collecting data from the partner organization. Finally, they offer suggestions for translating research into policy.

Physicians' reports of focused expertise in clinical practice.

Little is known about the prevalence of focused expertise (special areas of expertise within a clinical field) among physicians, yet such expertise may influence how care is delivered. We surveyed general internists, pediatricians, cardiologists, infectious disease specialists, and orthopedic surgeons to describe the prevalence of focused expertise and identify associated physician and practice characteristics. About one quarter of generalists and three quarters of specialists reported a focused expertise within their primary specialty. Hospital-based physicians more often reported such expertise, and physicians reimbursed by capitation less often reported expertise. Learning how focused expertise affects processes and outcomes of care will contribute to decisions about physician training and staffing of medical groups.

Use of hormone replacement therapy by postmenopausal women in the United States.

BACKGROUND: The benefits and risks of hormone replacement therapy (HRT) in postmenopausal women are not fully defined, and individual characteristics and preferences may influence decisions to use this therapy. Previous studies of postmenopausal women who use HRT have been conducted in local or highly selected cohorts or have not focused on current use. OBJECTIVE: To examine sociodemographic, clinical, and psychological factors associated with current use of HRT in a national population-based cohort. DESIGN: Random-digit telephone survey. SETTING: Probability sample of U.S. households with a telephone. PARTICIPANTS: 495 postmenopausal women 50 to 74 years of age in 1995. MEASUREMENTS: Current use of HRT. RESULTS: Current use of HRT was reported by 37.6% of women (58.7% of those who underwent hysterectomy and 19.6% of those who did not undergo hysterectomy; P = 0.001). In multivariable analyses, use of HRT was more common among women in the South (adjusted odds ratio, 2.67 [95% CI, 1.08 to 6.59]) and West (odds ratio, 2.76 [CI, 1.01 to 7.53]) than the Northeast. Use was more common among college graduates (odds ratio, 3.72 [CI, 1.29 to 10.71]) and less common among women with diabetes mellitus (odds ratio, 0.17 [CI, 0.05 to 0.51]). Other cardiac risk factors and most psychological characteristics were not associated with HRT use. CONCLUSIONS: Sociodemographic factors, such as region and education, may be more strongly associated with use of HRT than clinical factors, such as risk for cardiovascular disease. Future efforts should focus on understanding sociodemographic variations, defining which women are most likely to benefit, and targeting therapy to them.

Physicians' experiences and beliefs regarding informal consultation.

CONTEXT: Efforts to control medical expenses by emphasizing primary care and limiting specialty care may influence how physicians use informal or "curbside" consultation. OBJECTIVE: To understand physicians' use of and beliefs about informal consultation. DESIGN: Survey mailed in July 1997. PARTICIPANTS: Of a random sample of Massachusetts general internists, pediatricians, cardiologists, orthopedic surgeons (n=300 each), and infectious disease specialists (n=200) surveyed, 1225 were eligible and 705 (58%) responded. MAIN OUTCOME MEASURES: Self-reported use of and beliefs about informal consultation. RESULTS: Generalist physicians requested more informal consultations than specialists (median, 3 vs 1 per week; P<.001) and were asked to provide fewer (2 vs 5 per week; P<.001). In multivariate analyses, physicians in a health maintenance organization, multispecialty group, or single-specialty group requested more informal consultations than those in solo practice (82%, 40%, and 28% more, respectively; all P<.001) and were more often asked to provide them (43%, 63%, and 14% more, respectively; all P<.05). Physicians with at least 30% of their income from capitation requested 38% more and were asked to provide 46% more informal consultations than those with little or no income from capitation (both P<.001). Generalists' overall approval of informal consultation was greater than specialists' (mean 5.9 vs 5.1 on a 7-point Likert scale; P<.001), and approval was strongly associated with beliefs about how informal consultation affects quality of care (P<.001). CONCLUSIONS: Use of informal consultation is common, varies by specialty, practice setting, and capitation, and therefore may increase with current trends toward group practice and managed care. Because overall approval of informal consultation is strongly associated with beliefs about how it affects quality of care, this issue should be carefully considered by physicians who participate in informal consultation.