European Journal of Obstetrics & Gynecology and Reproductive Biology 184 (2015) 19–23
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The impact of gynecologic oncology training in the management of cancer patients: is it really necessary? A prospective cohort study Francesco Plotti, Stella Capriglione *, Andrea Miranda, Giuseppe Scaletta, Alessia Aloisi, Daniela Luvero, Roberto Ricciardi, Corrado Terranova, Carlo De Cicco Nardone, Roberto Angioli Department of Obstetrics and Gynaecology, Campus Bio Medico University of Rome, Italy
A R T I C L E I N F O
A B S T R A C T
Article history: Received 25 September 2014 Received in revised form 3 November 2014 Accepted 11 November 2014
Objectives: To assess patients’ perceptions of physician, nurse, and care organization quality of care and services received during hospitalization with or without a sub-specialized setting in gynaecological oncology. Study design: Consecutive patients affected by gynaecologic cancer, referred to the Division of Gynaecology of University Campus Bio-Medico of Rome to underwent to surgery (surgical ward) or to chemotherapy (medical ward) from January 2010 to April 2014, were enrolled. Eligible subjects were divided into two groups: Group A: standard unit care, consisting of doctors and nurses without a speciﬁc training and Group B: Expert unit care, consisting of doctors and nurses with speciﬁc training in gynecologic oncology. Patients were asked to complete the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Cancer Module (QLQ-C30) and the Patient Satisfaction Questionnaire (IN-PATSAT32). Results: The sample (n = 150) is organized into two groups: 78 patients (Group A) and 72 patients (Group B). Analysing the results of IN-PATSAT32, comparing Group A versus Group B, we ﬁnd statistically signiﬁcant difference considering doctors’ information provision (items 7–9) (p = 0.0470), nurses’ technical skills (items 12–14) (p = 0.0369) and nurses’ information provision (items 18–20) (p = 0.0089) and general satisfaction (item 32) (p = 0.0214). Conclusions: This study highlights the potential beneﬁts specialty training for doctors and nurses that work in an oncologic ward (surgical or medical). In fact, the necessity for a separate sub-specialty in gynaecological oncology and a distinct training programme may be the key to achieve the higher satisfaction in this setting of patients. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Gynecologic oncology Quality of life Training Subspecialty
Introduction Patient satisfaction’s and care quality are based on individual’s expectations, experiences and satisfaction in the service that patients received such as interpersonal processes and information [1,2]. In the last decades health care has adopted a more patientcentred approach. There has been increasing interest in patients’ evaluation of subjective variables such as quality of life (QoL) and care satisfaction, today these variables are the major endpoints of health care.
* Corresponding author at: Department of Obstetrics and Gynecology, University of Rome ‘‘Campus Bio-Medico’’, Via A´lvaro del Portillo, 200, 00128 Rome, Italy. Tel.: +39 3452572851; fax: +39 06 22541456. E-mail address: [email protected]
(S. Capriglione). http://dx.doi.org/10.1016/j.ejogrb.2014.11.015 0301-2115/ß 2014 Elsevier Ireland Ltd. All rights reserved.
Information about patient satisfaction is important to assess the quality of health services, moreover, patients accept and adhere better to care plans if they are satisﬁed. Patient assessment of care is important especially in oncology because of the intensity of both the illness and its treatments . Patient satisfaction is considered a multidimensional concept that must be evaluated using a variety of multi-item scales . The EORTC has a working group on QoL and one of the main tasks of this group is to develop questionnaires for assessing QoL in clinical trials. These instruments can also be used in clinical practice. The EORTC recently developed IN-PATSAT32, a questionnaire designed to assess the perception that cancer patients have of the quality of their hospital-based care: the quality of their doctors and nurses care, the quality of the organisation and the one of the services received with the hospital. Few patient satisfaction
F. Plotti et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 184 (2015) 19–23
questionnaires have been developed speciﬁcally for cancer patients [5–11]. The aim of this prospective study is to assess the satisfaction of hospitalized patients, affected by malignant gynaecological disease, regarding doctors and nurses care and aspects of care organisation and services received in the Division of Gynaecology of University Campus Bio-Medico of Rome, considering two groups: a standard unit care, consisting of doctors and nurses without a speciﬁc training (Group A) and an expert unit care, consisting of doctors and nurses subspecialized in gynaecological oncology (Group B). Patients were asked to complete the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Cancer Module (QLQ-C30) and the Patient Satisfaction Questionnaire (IN-PATSAT32).
Materials and methods Consecutive patients affected by gynaecological cancer, referred to the Division of Gynaecology of University Campus BioMedico of Rome from January 2010 to April 2014 to undergo 1st surgery (surgical ward) or to 1st chemotherapy cycle (medical ward), were considered for the study protocol. The institutional internal review board approved the study. Eligibility criteria included patients who need hospitalization for oncologic surgery or chemotherapy, age above 18 years and below 75 years, ability to provide informed consent and hospital stay of at least one day. This last criterion was deﬁned to be able to select patients with enough experience within the institution in order to let them ﬁll a questionnaire on care satisfaction. Exclusion criteria included physically or cognitively inability to understand and/or complete the questionnaire and had a life expectancy of less than 3 months (ECOG 3). Eligible subjects were divided into two groups, based on the current availability of beds in the hospital’s departments: patients followed by a standard unit care (Group A), consisting of gynaecologists doctors and nurses without a speciﬁc training in gynaecologic oncology. As regards doctors, they needed to have previously performed a rotation of 6 months in a gynaecologic oncology department during their residency. Instead, Group B consisted in a cohort patients followed by an expert unit care, composed by doctors and nurses with speciﬁc training in gynecologic oncology. Doctors and nurses with at least 3 consecutive years of experience in departments of surgical oncology and medical oncology were deﬁned as skilled in gynaecologic oncology. Patients were unaware about their type of unit care. However, for all patients surgery was always performed by an expert gynaecologic oncologist as well as the prescription of chemotherapy. Patients were asked to complete the EORTC Quality of Life Questionnaire-Cancer Module (QLQ-C30) (version 3.0)  and the Patient Satisfaction Questionnaire (IN-PATSAT32) (4) at hospital recovery. The EORTC QLQ-C30 contains scales and items addressing functional aspects of QoL and symptoms that commonly occur in patients with cancer. The EORTC QLQ-C30 is a speciﬁc questionnaire for assessing general Quality of Life (QoL) of cancer patients. The module consists of thirty items including ﬁve functioning domains (Physical, Role, Cognitive, Emotional and Social), three symptom scales (Fatigue, Pain, Nausea and Vomiting), global health and overall QoL scales, several single items that assess additional symptoms commonly reported by cancer patients (Dyspnoea, Insomnia, Appetite loss, Constipation and Diarrhoea) and the perceived ﬁnancial impact of the disease and treatment. The EORTC IN-PATSAT32 is composed of thirty-two items assessing cancer patients’ perception of the quality of hospital doctors and nurses, as well as selected aspects of the care
organization and hospital environment that are relevant across country settings [13,14]. The EORTC IN-PATSAT32 was conceptualised as containing eleven multi-item and 3 single-item scales. These include the doctors’ interpersonal skills, technical skills, information provision, availability scales; the nurses’ technical skills, interpersonal skills, information provision, availability scales; the other hospital staff interpersonal skills and information provision scale; the exchange of information single-item scale; the waiting time scale; the hospital access scale; the comfort single-item scale and the general satisfaction single-item scale. Patients were contacted before their discharge from hospital, informed of the objectives and procedures of the study, and solicited to participate. All questionnaires were distributed in the hospital and those who consent completed the EORTC QLQ-C30 and IN-PATSAT32 validated in Italian language, with the permission from the EORTC QoL group to use the Italian version in this speciﬁc study. The interview took place in a private counselling room in the hospital ward. The authors conducted all interview sessions to ensure consistency of participant’s response and to reduce inter-rate variability. All data were recorded, analysed using the scoring manual of the EORTC QoL and transformed to a 0–100 scale (Raw score) standard deviations (SD) [15,16] compare IN-PATSAT32 and EORTC QLQ-C30 items, we performed the analysis in each group using unpaired T test. Mean scores were calculated. Statistical signiﬁcance was set at a p value less than 0.05. Results From January 2010 to April 2014, 212 patients referred to our Department that meet all eligibility criteria are recruited into the study. Of these 212 patients, 62 (29%) did not complete fully the questionnaires (48.5% in Group A and 51.5% in Group B), so ﬁnally 150 patients were considered in this study. The sample is organized into two groups: 78 patients followed by a standard unit care, consisting of doctors and nurses without a speciﬁc training (Group A) and 72 patients followed by an expert unit care, consisting of doctors and nurses skilled in gynaecological oncology (Group B). The median age of the patients is 57 years, 120 (80%) have more than a compulsory educational level. No signiﬁcant differences (p < 0.001) have been found between each subgroup for age, education level, work setting, hospital stay, clinical and surgical features (Table 1). All the results of EORTC QLQ-C30 are summarized in Table 2. About ‘‘Global health Status’’ (items 29,30) in Group A the Raw score Standard deviation is 73.50 25.65, in Group B Raw score Standard deviation is 75.00 16.67. Therefore, two groups may be considered homogeneous. All the results of EORTC INPATSAT32 are summarized in Table 3. Analysing the results of IN-PATSAT32, comparing Group A versus Group B we ﬁnd statistically signiﬁcant difference considering doctors’ information provision (items 7–9) (p = 0.0470), nurses’ technical skills (items 12–14) (p = 0.0369) and nurses’ information provision (items 18–20) (p = 0.0089) and general satisfaction (item 32) (p = 0.0214). Therefore, a sub-analysis in each group was carried out, in order to identify the difference between surgical and medical wards patients. Regarding medical hospitalization, 43 (55%) and 39 (54%) patients underwent to chemotherapy, in Group A and in Group B, respectively. Analysing the results of IN-PATSAT32 in this speciﬁc setting of patients, we ﬁnd statistically signiﬁcant difference considering doctors’ information provision (items 7–9) (p = 0.01), nurses’ technical skills (items 12–14) (p = 0.02) and nurses’
F. Plotti et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 184 (2015) 19–23 Table 1 Socio-demographic characteristics of the sample (n = 150 patients). Group A N (%) Age Median Range Highest level of education n (%) Less than compulsory Compulsory school Post-compulsory school University level Marital status Single Married, cohabitant Separated, divorced, widow(er) Unknown Employment status Full time Part time Employment type Homemaker Student Unemployed Retired Hospital ward Surgical ward Medical ward Surgical ward Hospital stay (mean days) Complication rate (%) Medical ward Hospital stay (mean days) Complication rate (%) Type of surgical procedures Ovarian cancer cytoreduction Cervical cancer radical surgery Endometrial cancer surgery
78 (52%) 57.5 35–79
72 (48%) 56.8 35–77
Table 3 EORTC IN-PATSAT32: standard deviation, raw score and p value. p
Raw score Standard deviation
12 33 18 15
(15.4) (42.3) (23.1) (19.2)
17 26 17 12
(24) (36) (24) (16)
NS NS NS NS
18 45 9 6
(23.1) (57.7) (11.5) (7.7)
14 40 12 6
(20) (56) (16) (8)
NS NS NS NS
72 (92.3) 6 (7.7)
65 (90) 7 (10)
12 33 18 15
17 (24) 26(36) 17 (24) 12 (16)
NS NS NS NS
(15.4) (42.3) (23.1) (19.2)
35 (45%) 43 (55%)
33 (46%) 39 (54%)
11 (32%) 6 (17%) 18 (51%)
10 (30%) 7 (21%) 16 (49%)
NS NS NS
NS = not signiﬁcant.
information provision (items 18–20) (p = 0.004) and general satisfaction (item 32) (p = 0.01) (Table 4). Regarding surgical hospitalization, 35 (45%) and 33 (46%) patients underwent to oncological surgery, in Group A and in Group B, respectively. Analysing the results of IN-PATSAT32 in this speciﬁc setting of patients, we ﬁnd statistically signiﬁcant difference considering doctors’ information provision (items 7– 9) (p = 0.0360), nurses’ technical skills (items 12–14) (p = 0.0450) and nurses’ information provision (items 18–20) (p = 0.009) and general satisfaction (item 32) (p = 0.04) (Table 4).
Table 2 EORTC QLQ-C30: standard deviation and raw score. Group B
Raw score Standard deviation Physical functioning (items 1–5) Role functioning (items 6–7) Emotional functioning (items 21–24) Cognitive functioning (items 20, 25) Social functioning (items 26, 27) Fatigue (items 10,12,18) Nausea and vomiting (items 14,15) Pain (items 9,19) Dyspnoea (item 8) Insomnia (item 11) Appetite loss (item 13) Constipation (items 16) Diarrhoea (item 17) Financial difﬁculties (item 28) Global health status (items 29, 30)
Doctors Interpersonal skills (items 1–3) Technical skills (items 4–6) Information provision (items 7–9) Availability (items 10, 11) Nurses Technical skills (items 12–14) Interpersonal skills (items 15–17) Information provision (items 18–20) Availability (items 21, 22) Exchange of information (item 23) Other hospital personnel kindness and helpfulness, and information giving (items 24–26) Waiting time (performing medical tests/treatment, receiving medical tests results) (items 27, 28) Access (items 29, 30) Comfort/cleanness (item 31) General satisfaction (item 32) a
70.43 34.40 73.18 26.93 70.65 23.95 68.84 28.56 73.18 30.04 71.01 20.30 74.63 25.06 71.01 26.21 27.53 29.56 31.88 25.58 27.54 32.80 28.98 30.65 17.39 22.17 28.98 27.16 72.50 25.65
80.00 20.06 83.33 17.93 85.42 17.28 85.83 15.55 79.16 18.64 82.78 14.63 82.50 24.47 80.83 16.47 18.33 22.87 21.67 19.57 18.33 17.01 11.66 22.36 16.67 20.23 26.00 19.94 75.00 16.67
91.30 12.17 95.65 9.68
85.00 22.43 95.00 10.26
Comments In recent years there has been an increasing awareness of how patients perceive the quality of their care. In an extremely competitive environment, patient satisfaction has become a tool to gain attention and value. Hospitals and other health care centres are increasingly inclined to use this information for making important decisions regarding operational and treatment plans . Patient satisfaction data is often considered a surrogate indicator for the quality of care delivered by health care providers and hospitals . The assessment of patient satisfaction in an oncology setting is particularly considerable. Advances in diagnostic, treatment, supportive care and rehabilitation necessitate a continuous monitoring to determine if patients are satisﬁed about health care services that they are receiving, and to identify areas in which improvement is needed . To our knowledge, this is the ﬁrst Italian study to assess the satisfaction of hospitalized patients, affected by malignant gynaecological disease, regarding doctors and nurses care and aspects of care organisation and services received. Analysing the results of IN-PATSAT32, comparing Group A (standard unit care) versus Group B (expert unit care) we found statistically signiﬁcant difference considering doctors’ information provision, nurses’ technical skills and nurses’ information provision and general satisfaction. Probably, the difference of patient’s satisfaction between doctors and nurses is connected to the frequent contacts with the nurses instead of the doctors in the concrete material administration of the prescribed therapies.
p = 0.04a p = 0.321 p = 0.062 p = 0.217 p = 0.457 p = 0.0095 p = 0.760 p = 0.009a p = 0.047
Statistically signiﬁcant. a
p = 0.87 p = 0.42 p = 0.70
p = 0.0360a
p = 0.045a
p = 0.952 p = 0.091 p = 0.417 p = 0.375 p = 0.0068 p = 0.470 p = 0.004a p = 0.051 p = 0.90 p = 0.34
Medical ward’s patients Surgical ward’s patients
p = 0.51
p = 0.01a
p = 0.02a
Comfort/ cleanness (item 31) Access (items 29, 30) Waiting time (items 27, 28) Other (items 24–26) Exchange of information (item 23) Availability (items 10, 11) Technical skills (items 4–6) Interpersonal skills (items 1–3)
Information provision (items 7–9)
Technical skills (items 12–14)
Interpersonal skills (items 15–17)
Information provision (items 1 8–20)
Availability (items 21, 22)
Other Nurses Doctor
Table 4 p value for medical and surgical ward’s patients (Group A versus Group B) in EORTC IN-PATSAT32.
p = 0.01a
F. Plotti et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 184 (2015) 19–23 General satisfaction (item 32)
Therefore, a sub-analysis in each group was carried out, in order to identify the difference between surgical and medical wards patients. We observed the same statistically signiﬁcant difference in the same items. Even if a statistical cross analysis is not feasible, based on our sub-analysis results, medical ward’s patients seems to report a more weighted statistical difference compared to surgical ward’s patient, suggesting that probably this speciﬁc subset of patients have more necessities. Unfortunately, in literature there are only few studies that evaluate the impact of skilled care team on quality of life of gynaecologic patients [20,21]. Thus, the specialization level of hospitals and the surgical volume of gynecologists positively inﬂuence outcomes of surgery and survival, as reported by Vernooij et al. . The necessity for a separate sub-specialty in gynaecological oncology and a distinct training programme to achieve this was recognised by the American Board of Obstetrics and Gynaecology  in 1969 and subsequently the Royal College of Obstetrics and Gynaecology (RCOG) in 1982  who laid down clear guidelines, requirements and curricula for training. An Oncology Certiﬁed Nurse (OCN) has the knowledge necessary to affect positive patient outcomes. An OCN is able to discuss side-effect management, treatment plans, further options, resources and support . Presumably, the main determinant of patient satisfaction is the capacity of hospital staff to recognize and understand patients’ state of mind, as well as their emotional state, in a word, to establish empathy. This becomes crucial in the treatment of diseases with awful psychological impact, such as cancer, in which difﬁculties to be faced involve not only clinical symptoms, but also socio-economic factors, psychological stress and all the dimensions of QoL . Many malpractice suits are brought not because of malpractice nor even because of complaints about the quality of medical care but as an expression of anger about some aspect of patient-doctor relationships and communications . Patient satisfaction also affect their compliance regarding treatment and follow up which must be submitted. Compliance is an important issue in medical care, in fact the lack of compliance cause a considerable ﬁnancial burden upon health care systems. Furthermore compliance to treatment, to advice or to lifestyle changes is the key link between process and outcome in medical care . Cancer patients and their relatives claim that doctors and nurses are not only medical and technical experts, but also able to communicate professionally with them. Most patients prefer accurate information about diagnosis, prognosis, treatments, side effects, and quality of life issues, something that hospital staff do not always provide and appreciate an empathic way to give this information [29,30]. Most oncologists and oncology nurses consider communication skills essential for their daily work. However, some are skeptical that communication skills can be taught effectively; they either believe that these skills reﬂect personality and genuine talent, and therefore cannot be improved, or that improvement comes with time and experience . Contrary to this unbelief it is however desirable that nurses and doctors specialized in oncology should have a speciﬁc assistance and communication skills training, as an integral part of their professional educational curriculum. The aim of this training should be to improve the communication and assistance with patients and among hospital staff. There should be a constant attempt to evaluate the efﬁcacy of this training, to insure and enhance the quality of training itself. The attempt to improve the psychosocial dimension of care in oncology should not be restricted to communication skills training, but also should include detection and therapy of psychosocial distress in patients and their relatives. Expanding the psychosocial
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dimension of oncology’s staff means also to acknowledge the importance of the emotional equilibrium. The treatment process is a vital time for an oncologic patient, so doctors and nurses play a key role during that time, because they are usually responsible for the administration of treatment. This study highlights the need of speciﬁc training for doctors and nurses that work in an oncologic ward. In fact, the necessity for a separate sub-specialty in gynaecological oncology and a distinct training programme seems to be the key to achieve the higher satisfaction in this setting of patients. It is important to keep in mind that even if patient’s perceptions are really important, other quality metrics, such as adherence to guidelines, complication rates, length of stay, time to progression, survival, are equally fundamental. For these reasons, evaluate the correlation between patient’s perceptions and measurable quality metrics may be the object of further analysis. Future studies can also be used to evaluate the responsiveness of the questionnaire to changes (planned or unplanned) in the structure and process of health care organization and care, after a speciﬁc training of doctors and nurses in oncology. References  Pascoe GC. Patient satisfaction in primary health care: a literature review and analysis. Eval Program Plan 1983;6:185–210.  Loblaw DA1, Bezjak A, Singh PM, et al. Psychometric reﬁnement of an outpatient, visit-speciﬁc satisfaction with doctor questionnaire. Psychooncology 2004;13:223–34.  Sitzia J. How valid and reliable are patient satisfaction data? An analysis of 195 studies. Int J Qual Health Care 1999;4:319–28.  Bre´dart A, Bottomley A, Blazeby JM, et al. An international prospective study of the EORTC cancer in-patient satisfaction with care measure (EORTC IN-PATSAT32). Eur J Cancer 2005;41:2120–31.  Oberst MT. Patients’ perceptions of care, measurement of quality and satisfaction. Cancer 1984;53:2366–75.  Wiggers JH, Donovan KO, Redman S, Sanson-Fisher RW. Cancer patient satisfaction with care. Cancer 1990;66:610–6.  Loblaw DA, Bezjak A, Bunston T. Development and testing of a visit-speciﬁc patient satisfaction questionnaire: the Princess Margaret Hospital Satisfaction with Doctor Questionnaire. J Clin Oncol 1999;17:1931–8.  Defossez G, Mathoulin-Pelissier S, Ingrand I, Gasquet I, Sifer-Riviere L, Ingrand P. Satisfaction with care among patients with non-metastatic breast cancer development and ﬁrst steps of validation of the REPERES-60 questionnaire. BMC Cancer 2007;7:129.  Yun YH, Kim SH, Lee KM, et al. Patient reported assessment of quality care at end of life: development and validation of Quality Care Questionnaire-End of Life (QCQ-EOL). Eur J Cancer 2006;42:2310–7.  Radwin L, Alster K, Rubin KM. Development and testing of the Oncology Patients’ Perceptions of the Quality of Nursing Care Scale. Oncol Nurs Forum 2003;30:283–90.  Abetz L, Coombs JH, Keininger DL, et al. Development of the cancer therapy satisfaction questionnaire: item generation and content validity testing. Value Health 2005;8(Suppl 1):S41–53.
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