Despite the drumbeat of demand for “patient-centered care,” a survey of breast surgeons found that most respondents have not adopted several practices consistent with that concept.
The vast majority of surgeons reported that, in the majority of cases, they did not discuss a patient's treatment plan with a medical oncologist, radiation oncologist, or plastic surgeon before operating on a breast cancer patient. Similarly, about two-thirds of surgeons said that few or almost none of their patients received decision support help from their practice.
The findings (Medical Care 2010; 48:45-51), from a survey of breast surgeons in Los Angeles and Detroit, document a disconnect between the practice of medicine advocated by organizations like the Institute of Healthcare Improvement and the Institute of Medicine and actual practice.
The survey sought to discover whether more experienced breast surgeons and those who practice in a more specialized setting make greater use of certain processes—for example, discussing treatment plans with other physicians or making decision support aids, such as patient support groups, videos about treatment issues, or presentations about breast cancer, available to their patients—more frequently than less experienced or general surgeons.
The major finding: Very few breast surgeons are using those processes, regardless of their experience level or level of specialization.
“The fact of the matter is that the uptake is not nearly as great as people might think it is, given today's emphasis on these kinds of quality-improvement processes,” said the lead author, Steven J. Katz, MD, Professor of Internal Medicine at the University of Michigan Health Systems.
That said, nearly 33% of surgeons who practice in a teaching program said the majority of their patients received multidisciplinary physician communication before surgery, compared with just 17% of surgeons in non-teaching programs. About one-third of breast surgery specialists in teaching programs reported that most of their patients received decision support from their practice versus just 5% of general surgeons working in community settings.
The study of surgeons is connected to a study of 3,133 women in the Los Angeles and Detroit areas who were diagnosed with breast cancer between June 2005 and February 2007. Using patient reports and information from pathology reports, the researchers identified an attending surgeon for 99% of those patients.
Chronic Care Model
The research team used the Chronic Care Model, developed several years ago by researchers at Group Health Research Institute, as the basis for creating the patient and practice management process measures used in the study. The Chronic Care Model identifies the elements of a health care system that encourage high-quality chronic disease care; thus, the researchers chose patient management processes they believe encourage the best quality care for breast cancer patients.
Commission on Cancer
The study received support from the Commission on Cancer of the American College of Surgeons.
“I found it a little disturbing that all of those [patient-management] practices were underpenetrated,” said David P. Winchester, MD, the Commission's Medical Director for Cancer Programs.
He said he was particularly concerned about the infrequency with which breast surgeons discuss their cases with other cancer caregivers before operating. He and other breast cancer experts at the National Accreditation Program for Breast Centers feel so strongly about such communication that the use of an interdisciplinary breast cancer conference is a core requirement for accreditation.
Dale Collins, MD, Medical Director of Comprehensive Breast Oncology Program at Dartmouth-Hitchcock Norris Cotton Cancer Center, though, read the findings differently: “If anything, I was surprised that there were as many using [the decision-support practices] as there were reported,” she said.
Dr. Collins, a breast surgeon, is Director of the Center for Informed Choice at Dartmouth Institute for Health Policy and Clinical Practice and Medical Director of the Center for Shared Decision-Making. In those roles, she is one of the leading advocates for the idea that breast cancer patients—and indeed all patients—should have access to information, a variety of resources, and an established process that help them to understand treatment options and be proactively involved in choosing their course of treatments.
Lack of Reimbursement a Factor
Dr. Collins said that although she believes awareness of patient decision support is growing among breast surgeons, the lack of reimbursement for those processes hinders adoption. For example, establishing a patient support group is only possible if a breast cancer surgery team can afford to provide staff without reimbursement.
“You have to be part of an organized medical center to implement a practice like that and have some support from the medical center for additional resources, because there is no reimbursement model for any of these activities,” she said.
Dr. Katz and his coauthors speculate that the low uptake of the patient and practice management processes they reviewed indicate that surgeons are not convinced of their value or that there are logistical or cost barriers to putting them to use.
The fact that 318 of the 419 surgeons responded to the survey shows that breast surgeons are concerned about the quality of care they are delivering, Dr. Katz said. Beyond that, the research team partnered with the American College of Surgeons to provide continuing medical education credit for physicians who visited a website that reported the study results—and about 40% of the participating surgeons visited the site.