Original Article
Are Primary Care Providers Prepared to Care for Survivors of Breast Cancer in the Safety Net? Aaron J. Dawes, MD1,2,3; Marian Hemmelgarn, MPH4; David K. Nguyen, MD1; Greg D. Sacks, MD, MPH1,3; Sheilah M. Clayton, MD5,6; Jacqueline R. Cope, MD, MPH7,8; Patricia A. Ganz, MD9,10; and Melinda Maggard-Gibbons, MD, MSHS1,2,4
BACKGROUND: With the growing number of survivors of breast cancer outpacing the capacity of oncology providers, there is pressure to transition patients back to primary care. Primary care providers (PCPs) working in safety-net settings may have less experience treating survivors, and little is known about their knowledge and views on survivorship care. The current study was performed to determine the knowledge, attitudes, and confidence of PCPs in the safety net at delivering care to survivors of breast cancer. METHODS: A modified version of the National Cancer Institute’s Survey of Physician Attitudes Regarding Care of Cancer Survivors was given to providers at 2 county hospitals and 5 associated clinics (59 providers). Focus groups were held to understand barriers to survivorship care. RESULTS: Although the majority of providers believed PCPs have the skills necessary to provide cancer-related follow-up, the vast majority were not comfortable providing these services themselves. Providers were adherent to American Society of Clinical Oncology recommendations for mammography (98%) and physical examination (87%); less than one-third were guidelineconcordant for laboratory testing and only 6 providers (10%) met all recommendations. PCPs universally requested additional training on clinical guidelines and the provision of written survivorship care plans before transfer. Concerns voiced in qualitative sessions included unfamiliarity with the management of endocrine therapy and confusion regarding who would be responsible for certain aspects of care. CONCLUSIONS: Safety-net providers currently lack knowledge of and confidence in providing survivorship care to patients with breast cancer. Opportunities exist for additional training in evidence-based guidelines and improved coordination of C 2014 American Cancer Society. care between PCPs and oncology specialists. Cancer 2015;121:1249-56. V KEYWORDS: breast cancer, survivorship, safety-net providers, primary care physicians.
INTRODUCTION Breast cancer is the second most common cancer in the United States and the most common among women. With improvements in treatment elevating 5-year survival rates close to 90%, survivorship care continues to gain importance.1 Currently, there are >2.8 million survivors of breast cancer in the United States, with projections of a 30% increase within 10 years.2 The oncology workforce, however, is limited, with shortages of 2500 to 4000 providers expected by 2020.3 Given this disparity, more patients will need to transition survivorship care from specialty clinics to primary care. Although many primary care providers (PCPs) currently care for cancer survivors, their roles are typically limited to non-cancer-related conditions or to working in conjunction with oncologists.4 Only a small percentage of PCPs provide the multidimensional services laid out by the Institute of Medicine (IOM), including monitoring for disease recurrence, identifying late treatment effects,5 and managing emotional health.2,6,7 Previous work has focused on PCPs working in high-resource, academic settings;8 less is known about the preparedness of nonphysician providers or those caring primarily for poor and uninsured populations: the so-called medical “safety net” of public hospitals, federally qualified health centers, and county-operated clinics.9 As transitions to primary care may disproportionately affect Corresponding author: Aaron J. Dawes, MD, Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, B711, Los Angeles, CA 90095; Fax: (310) 267-0369; [email protected] 1 Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California; 2VA Greater Los Angeles Healthcare System, Los Angeles, California; 3Robert Wood Johnson Foundation Clinical Scholars Program, University of California at Los Angeles, Los Angeles, California; 4 Department of Surgery, Olive View/University of California at Los Angeles Medical Center, Sylmar, California; 5Division of Cancer Research and Training, Department of Medicine, Martin Luther King Jr/Charles R. Drew University Medical Center, Los Angeles, California; 6Martin Luther King, Jr. Multi-Service Ambulatory Care Center, Los Angeles, California; 7Department of Family Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California; 8 Ambulatory Care Network, Los Angeles County Department of Health Services, Los Angeles, California; 9Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California; 10Jonsson Comprehensive Cancer Center, University of California at Los Angeles, Los Angeles, California
This article has been contributed to by US Government employees and their work is in the public domain in the USA. Presented at the 2014 Annual Scientific Meeting of the Southern California Chapter of the American College of Surgeons; January 17-19, 2014; Santa Barbara, CA. Additional Supporting Information may be found in the online version of this article. DOI: 10.1002/cncr.29201, Received: October 1, 2014; Revised: November 10, 2014; Accepted: November 17, 2014, Published online December 23, 2014 in Wiley Online Library (wileyonlinelibrary.com)
Cancer
April 15, 2015
1249
Original Article TABLE 1. Overview of the SPARCCS Instrument Survey Domains Demographics and practice setting
Knowledge and confidence Current clinical practices Preferred model for survivorship care
Question Elements Medical specialty, academic degree, site (clinic, hospital), number of patients with breast cancer treated within the last year, previous training in survivorship Self-reported confidence at delivering individual survivorship services, attitudes regarding the PCP’s role in survivorship care in general Ordering patterns for follow-up services (PCP, oncologist, shared), beliefs regarding the ideal frequency of surveillance testing Choice between 5 structural models for delivering survivorship care to patients with breast cancer
Abbreviations: PCP, primary care provider; SPARCCS, National Cancer Institute’s Survey of Physician Attitudes Regarding Care of Cancer Survivors.
resource-limited settings, there is a need to understand their readiness and to identify potential barriers to delivering high-quality survivorship care. The current study surveyed PCPs working in safetynet settings to assess their knowledge of, attitudes toward, and confidence in providing survivorship care to patients with breast cancer. We primarily sought to identify gaps in knowledge, characterize practice patterns, and place our results within the context of national data. We also used qualitative sessions to assess providers’ concerns and elucidate potential challenges to the transition of survivorship care. MATERIALS AND METHODS We surveyed physician and nonphysician providers from 2 primary care networks within a public safety-net system (Los Angeles County Department of Health Services [DHS]) regarding survivorship care, and conducted supplemental qualitative focus groups. This study was approved by the Institutional Review Boards at the Olive View Medical Center, University of California at Los Angeles, Charles R. Drew University of Medicine and Science, and Jonsson Comprehensive Cancer Center. Sample and Recruitment
Physicians, nurse practitioners, and physician assistants working in internal medicine, family medicine, women’s health, and obstetrics/gynecology were eligible to receive the survey. Recruitment occurred at health centers and clinics affiliated with 2 large, nonprofit primary care networks providing low-income and indigent medical care: 1) DHS; and 2) Valley Care Community Consortium, a health and mental health collaborative under contract with DHS to care for residents of Los Angeles’s San Fernando and Santa Clarita valleys. Providers received a study information letter along with a request for participation. We used a variety of methods to distribute the survey including hard copy, 1250
mail, E-mail, and online. Four attempts were made to contact nonresponsive providers via E-mail and telephone (see online supporting information). Providers were not compensated for their participation. Survey Overview
We used an abridged version of the National Cancer Institute’s Survey of Physician Attitudes Regarding the Care of Cancer Survivors. The survey was designed to capture knowledge, attitudes, and practices of PCPs and oncologists regarding survivors of breast and colon cancer.8 For the current study, questions not related to breast cancer or the role of PCPs were removed, and one question was added regarding level of training (physician vs nonphysician). An overview of survey domains is provided in Table 1 (see online supporting information for full survey instrument). Provider demographics and practice setting were recorded (ie, number of providers, practice type, patient load, insurance, capitated vs fee for service, and time spent in clinical vs administrative roles). Respondents were divided into subgroups based on categories from a previously published national survey (ie, physician vs nonphysician, providers spending at least 90% effort on patient care vs
Are Primary Care Providers Prepared to Care for Survivors of Breast Cancer in the Safety Net? Aaron J. Dawes, MD1,2,3; Marian Hemmelgarn, MPH4; David K. Nguyen, MD1; Greg D. Sacks, MD, MPH1,3; Sheilah M. Clayton, MD5,6; Jacqueline R. Cope, MD, MPH7,8; Patricia A. Ganz, MD9,10; and Melinda Maggard-Gibbons, MD, MSHS1,2,4
BACKGROUND: With the growing number of survivors of breast cancer outpacing the capacity of oncology providers, there is pressure to transition patients back to primary care. Primary care providers (PCPs) working in safety-net settings may have less experience treating survivors, and little is known about their knowledge and views on survivorship care. The current study was performed to determine the knowledge, attitudes, and confidence of PCPs in the safety net at delivering care to survivors of breast cancer. METHODS: A modified version of the National Cancer Institute’s Survey of Physician Attitudes Regarding Care of Cancer Survivors was given to providers at 2 county hospitals and 5 associated clinics (59 providers). Focus groups were held to understand barriers to survivorship care. RESULTS: Although the majority of providers believed PCPs have the skills necessary to provide cancer-related follow-up, the vast majority were not comfortable providing these services themselves. Providers were adherent to American Society of Clinical Oncology recommendations for mammography (98%) and physical examination (87%); less than one-third were guidelineconcordant for laboratory testing and only 6 providers (10%) met all recommendations. PCPs universally requested additional training on clinical guidelines and the provision of written survivorship care plans before transfer. Concerns voiced in qualitative sessions included unfamiliarity with the management of endocrine therapy and confusion regarding who would be responsible for certain aspects of care. CONCLUSIONS: Safety-net providers currently lack knowledge of and confidence in providing survivorship care to patients with breast cancer. Opportunities exist for additional training in evidence-based guidelines and improved coordination of C 2014 American Cancer Society. care between PCPs and oncology specialists. Cancer 2015;121:1249-56. V KEYWORDS: breast cancer, survivorship, safety-net providers, primary care physicians.
INTRODUCTION Breast cancer is the second most common cancer in the United States and the most common among women. With improvements in treatment elevating 5-year survival rates close to 90%, survivorship care continues to gain importance.1 Currently, there are >2.8 million survivors of breast cancer in the United States, with projections of a 30% increase within 10 years.2 The oncology workforce, however, is limited, with shortages of 2500 to 4000 providers expected by 2020.3 Given this disparity, more patients will need to transition survivorship care from specialty clinics to primary care. Although many primary care providers (PCPs) currently care for cancer survivors, their roles are typically limited to non-cancer-related conditions or to working in conjunction with oncologists.4 Only a small percentage of PCPs provide the multidimensional services laid out by the Institute of Medicine (IOM), including monitoring for disease recurrence, identifying late treatment effects,5 and managing emotional health.2,6,7 Previous work has focused on PCPs working in high-resource, academic settings;8 less is known about the preparedness of nonphysician providers or those caring primarily for poor and uninsured populations: the so-called medical “safety net” of public hospitals, federally qualified health centers, and county-operated clinics.9 As transitions to primary care may disproportionately affect Corresponding author: Aaron J. Dawes, MD, Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, B711, Los Angeles, CA 90095; Fax: (310) 267-0369; [email protected] 1 Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California; 2VA Greater Los Angeles Healthcare System, Los Angeles, California; 3Robert Wood Johnson Foundation Clinical Scholars Program, University of California at Los Angeles, Los Angeles, California; 4 Department of Surgery, Olive View/University of California at Los Angeles Medical Center, Sylmar, California; 5Division of Cancer Research and Training, Department of Medicine, Martin Luther King Jr/Charles R. Drew University Medical Center, Los Angeles, California; 6Martin Luther King, Jr. Multi-Service Ambulatory Care Center, Los Angeles, California; 7Department of Family Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California; 8 Ambulatory Care Network, Los Angeles County Department of Health Services, Los Angeles, California; 9Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California; 10Jonsson Comprehensive Cancer Center, University of California at Los Angeles, Los Angeles, California
This article has been contributed to by US Government employees and their work is in the public domain in the USA. Presented at the 2014 Annual Scientific Meeting of the Southern California Chapter of the American College of Surgeons; January 17-19, 2014; Santa Barbara, CA. Additional Supporting Information may be found in the online version of this article. DOI: 10.1002/cncr.29201, Received: October 1, 2014; Revised: November 10, 2014; Accepted: November 17, 2014, Published online December 23, 2014 in Wiley Online Library (wileyonlinelibrary.com)
Cancer
April 15, 2015
1249
Original Article TABLE 1. Overview of the SPARCCS Instrument Survey Domains Demographics and practice setting
Knowledge and confidence Current clinical practices Preferred model for survivorship care
Question Elements Medical specialty, academic degree, site (clinic, hospital), number of patients with breast cancer treated within the last year, previous training in survivorship Self-reported confidence at delivering individual survivorship services, attitudes regarding the PCP’s role in survivorship care in general Ordering patterns for follow-up services (PCP, oncologist, shared), beliefs regarding the ideal frequency of surveillance testing Choice between 5 structural models for delivering survivorship care to patients with breast cancer
Abbreviations: PCP, primary care provider; SPARCCS, National Cancer Institute’s Survey of Physician Attitudes Regarding Care of Cancer Survivors.
resource-limited settings, there is a need to understand their readiness and to identify potential barriers to delivering high-quality survivorship care. The current study surveyed PCPs working in safetynet settings to assess their knowledge of, attitudes toward, and confidence in providing survivorship care to patients with breast cancer. We primarily sought to identify gaps in knowledge, characterize practice patterns, and place our results within the context of national data. We also used qualitative sessions to assess providers’ concerns and elucidate potential challenges to the transition of survivorship care. MATERIALS AND METHODS We surveyed physician and nonphysician providers from 2 primary care networks within a public safety-net system (Los Angeles County Department of Health Services [DHS]) regarding survivorship care, and conducted supplemental qualitative focus groups. This study was approved by the Institutional Review Boards at the Olive View Medical Center, University of California at Los Angeles, Charles R. Drew University of Medicine and Science, and Jonsson Comprehensive Cancer Center. Sample and Recruitment
Physicians, nurse practitioners, and physician assistants working in internal medicine, family medicine, women’s health, and obstetrics/gynecology were eligible to receive the survey. Recruitment occurred at health centers and clinics affiliated with 2 large, nonprofit primary care networks providing low-income and indigent medical care: 1) DHS; and 2) Valley Care Community Consortium, a health and mental health collaborative under contract with DHS to care for residents of Los Angeles’s San Fernando and Santa Clarita valleys. Providers received a study information letter along with a request for participation. We used a variety of methods to distribute the survey including hard copy, 1250
mail, E-mail, and online. Four attempts were made to contact nonresponsive providers via E-mail and telephone (see online supporting information). Providers were not compensated for their participation. Survey Overview
We used an abridged version of the National Cancer Institute’s Survey of Physician Attitudes Regarding the Care of Cancer Survivors. The survey was designed to capture knowledge, attitudes, and practices of PCPs and oncologists regarding survivors of breast and colon cancer.8 For the current study, questions not related to breast cancer or the role of PCPs were removed, and one question was added regarding level of training (physician vs nonphysician). An overview of survey domains is provided in Table 1 (see online supporting information for full survey instrument). Provider demographics and practice setting were recorded (ie, number of providers, practice type, patient load, insurance, capitated vs fee for service, and time spent in clinical vs administrative roles). Respondents were divided into subgroups based on categories from a previously published national survey (ie, physician vs nonphysician, providers spending at least 90% effort on patient care vs
