Physician Incentives for Shared Management of Childhood Cancer Patients

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Physician

Incentives

for Shared

Management

of Childhood

Cancer

Patients

Faye H. Strayer, PhD, Carol C. Fethke, PhD, C. Thomas Kisker, MD,

and Nancy G. DeKrey, MS

From the Department of Pediatrics, University of Iowa, College of Medicine, Iowa City

ABSTRACT. Four years’

experiences

of

69 primary care

physicians who delivered more than 70% of the chemo-therapy to 174 children with cancer were assessed. Five academic pediatric oncologists were responsible for

diag-nosis, assignment to a clinical trial protocol, and overall management. The academicians saw the patients at

di-agnosis and at regularly scheduled intervals but provided care for less than 30% of the outpatient visits. Factors examined included: (1) why the primary care physicians agreed to participate in the care of these patients, (2) how

they thought their participation affected the patient and the patient’s family, (3) how participation affected their personal and professional development, (4) how partici-pation affected their practice, (5) what their perceptions were concerning the merits of traditional specialist man-agement, and (6) their overall evaluation of the Iowa shared-management program. The initial agreement by primary care physicians to participate in shared

manage-ment was related to their perception that it would

im-prove the overall care of their patients. The physicians agreed that the program saved the family time and money, was of educational value, personally satisfying, and not economically detrimental to their practice. They

did not identify areas where specialist management had

clear advantages over shared management and none re-ported dissatisfaction with this management program.

Pediatrics 67:833-837, 1981; pediatric oncology, shared management, pediatrics.

Modern treatment of children with cancer has

resulted in significant improvement in survival. This improvement is in part the result of clinical studies conducted by academic pediatric oncolo-gists. In Iowa, clinical studies of children with can-cer are shared by academic pediatric oncologists at the University of Iowa cancer center and a primary

care

physician near the patient’s home. Pediatric

Received for publication July 16, 1980; accepted Oct 2, 1980.

Reprint requests to (C.T.K.) 247A Medical Laboratories,

Uni-versity of Iowa, Iowa City, IA 52242.

oncologists at the University of Iowa are responsible for the diagnosis, staging, assignment of newly di-agnosed patients to a treatment protocol, and

over-all management of the clinical trials. Although the patients return to the university for follow-up at

regularly scheduled intervals and the primary care physicians report to the center the results of each examination and treatment, more than 70% of the outpatient chemotherapy and approximately 50% of the radiation therapy is given by local physicians in the child’s community.

A previous paper,’ which described the

organi-zation of the shared-management program and evaluated it, showed no significant differences in the quality of care given to patients treated under this shared-management program as compared with patients treated by academic pediatric oncol-ogists only. A second paper2 showed families receiv-ing shared-management care were able to reduce costs by 40% over the cost of specialist management. Examined here are the motiviations and opinions of the group of primary care physicians providing shared-management care for children with cancer. Children with cancer who are involved in clinical trials are seen frequently and require the adminis-tration of highly toxic agents. Thus, close coordi-nation of therapy with other physicians, additional record keeping, and stringent reporting procedures on the physicians who care for them are required.

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TABLE 1. Physicians’ Retrospectively Reported Reasons for Their Initial Decision

Management Care Program for Pediatric Cancer Patients (N = 69)

to Participate in Iowa

Shared-Most Impor- Contributing tant Reason Reason for In-for Initial Par- itial

Participa-ticipation tion

No. % No. %

It would result in better overall care for patient 21 30.5 61 88

It would improve the quality of life for patient 13 19 67 97

It would help patient’s family to know there was physician nearby familiar with 7 10 59 86 patient’s anticancer care program

It would save money for family 5 7 62 90

It would save travel time for family 4 6 60 87

It would allow sharing of responsibility for care of seriously ill patient with academic 3 4 56 81 specialist

It would allow primary care physician to participate in clinical research program to 3 4 33 48 determine best management of childhood cancer

It would permit primary care physician to use newer, better drugs for patient which 1 1.5 40 58 would not otherwise be available

It would allow patient to be in clinical research program 1 1.5 33 48

It would help maintain or increase physician’s income 1 1.5 5 7

It would provide continuing medical education for physician participating in shared- 0 . .. 61 88

management care

It would provide degree of professional prestige for physician 0 ... 26 38

Other (write-in) responses 10 15 11 16

METHODS

One hundred eleven physicians who had partici-pated in the Iowa shared-management system of childhood cancer patients from 1976 to 1980 were

surveyed by mail questionnaire. A telephone survey was conducted of a randomly selected sample of the physicians who did not respond to the question-naire.

Seventy-seven physicians responded to the

ques-tionnaire

and 69 questionnaires were used in the statistical analysis. Of the eight excluded from the analysis reported here, three were completed by Board-certified oncologists in private practice,

three questionnaires were incomplete, one was com-pleted by a physician who had not given chemo-therapy to his patient, and one was completed by a physician who had treated a patient only on occa-sion for his partner.

The 69 physicians included 38 pediatricians, 19 family practitioners, six general practitioners, four internists, and two general surgeons.

Geographi-caily,

59 of the physicians were located in Iowa, nine in western Illinois, and one in Missouri. A total of 174 children with cancer were cared for under shared management by these physicians. The mean number of patients per physician was 2.52 (range 1 to 9). Of the 69 physicians, 54 had seen their cancer patients for more than ten visits.

RESULTS AND DISCUSSION

The questionnaire examined the physician’s

in-centives for participating in the

shared-manage-ment program by asking them to identify retrospec-tively factors that influenced their initial decision.

Of the total, 97% anticipated the program would

improve the quality of the patient’s life. More than 80% thought the program would save the family time and money, would result in better overall care for the patient, and would help the family by having a physician nearby who was familiar with the pa-tient’s therapy plan; 88% also said learning to care for this type of patient would be a form of contin-uing medical education. Of the total, 81% said it

allowed them to share the responsibility for care of a seriously ill patient with another physician, and

93% rejected the idea that their motivation for becoming participants involved the expectation that the program would help maintain or increase their income. A weighted ranking of the responses

concerning

which was the most important reason for their initial decision to participate revealed two clear priorities: better quality of care for the patient and improved quality of life for the patient (Table 1).

There were some differences between physicians who had seen patients more than ten times and those who had not seen patients that often. Those

who had seen their cancer patients more than ten

times ranked third that they expected it would help the family to know that there was a physician nearby familiar with the patient’s anticancer care

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TABLE 2. Primary Care Physicians’ Perceptions of Effects of Shared-Management Care (N = 69)*

Mean ± SD

1.52 ± 1.04 1.62 ± 0.71 1.65 ± 0.87

2.01 ± 0.96

2.61 ± 1.18

1.97 ± 0.96

2.16 ± 1.04

2.16 ± 1.02

2.18 ± 0.83

2.20 ± 1.08 2.56 ± 1.17

2.71 ± 1.09

1.69 ± 0.88 2.07 ± 1.13 2.18 ± 0.94

3.83 ± 1.32

4.33 ± 1.36 4.36 ± 1.46 4.45 ± 1.42

5.10 ± 1.02 * Possible responses to each statement were equated with the following numerical values:

1, strongly agree; 2, moderately agree; 3, slightly agree; 4, slightly disagree; 5, moderately disagree; and 6, strongly disagree.

findings suggest that there is educational value to

this type of management that becomes apparent to the physician with continued participation.

The physician’s view of the effect of the shared-management program effect on the patient and the patient’s family as well as its effect on his/her own personal and professional development and private practice were also examined. The physicians were asked to indicate on a six-point Likert Scale their

degree of agreement or disagreement to a series of statements. Mean scores and standard deviations for each statement are presented in Table 2.

The first set of statements dealt with the physi-.

cian’s perception of the effects of the program on the patient and the patient’s family. There was a moderate to strong agreement that the program

saved the family time, improved the patient’s qual-ity of life, and eased the family’s economic burden. The savings of time and money were confirmed by the authors’ studies2 of the economic aspects of shared management.

The second set of statements dealt with the

ef-fects of the shared-management program on the physician’s personal and professional development. Scores indicated agreement that shared manage-ment gave personal satisfaction to the physician. Scores also indicated that it stimulated them to learn more about childhood cancer diagnosis, chemotherapy, and care, that it increased their understanding of the prescribed cancer treatment, that it allowed them to share the emotional load of

caring for this type of patient, and that it strengthened their relationship with the academic

physicians. Overall their opinion wavered between slight and moderate agreement that the program eased their concern for administering cancer chemotherapy and they only slightly agreed that the program improved their relationship with other

seriously ill patients.

A third set of statements dealt with the effects of

shared management upon the physician’s own prac-tice. There was a moderate to strong perception by the physicians that shared management improved the quality of care that they were able to deliver to

Perceived effects on patients and their families Saved family time

Improved patient’s quality of life Eased family’s economic burden

Improved quality of care by utilizing family to assist in keeping track of therapy schedules

Comforted family to be part of cancer research project

Perceived effects on physicians’ personal and professional develop-ment

Given me personal satisfaction in caring for childhood cancer patient

Stimulated me to learn more about childhood cancer diagnosis, chemotherapy, and care

Helped me better understand treatment prescribed for my patient by specialists

Allowed me to share emotional load of caring for seriously ill patient

Strengthened my relationship with University of Iowa physicians Eased my concern in administering cancer chemotherapy

Improved my relationship with other seriously ill patients

Perceived effects on physicians’ practice Improved quality of care delivered to patient Expanded treatment choices offered my patients

Provided a way to monitor and audit administration of potent drugs

Has increased laboratory income of local hospital or laboratory facility

Generated more referrals to me of similar patients Required too much time for record keeping

Taken more time than I should devote to this type of patient in my practice

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TABLE 3. Changes in Iowa Shared-Management Pro-gram Recommended by Participating Primary Care Phy-sicians (N = 69)

No. of Physi-cians 33 22 12 10 4 2 5 the patient. The previous study’ demonstrated that

shared-management care was in fact comparable in quality to specialist care. There was agreement that the program provided a way to expand treatment choices offered to patients and provided a way to

monitor and audit the administration of potent drugs. They were split on whether the program increased income oflocal laboratories and hospitals. In general, physicians expressed slight to

moder-ate disagreement with statements suggesting that shared management generated referrals to them of

similar patients, required too much time for record keeping, or took more of their medical practice time than should be devoted to this type of patient. They expressed moderate disagreement with the state-ment that the system had caused the practice to

lose money.

Even though the surveyed group of physicians were participants in shared-management, it was thought that they might regard some aspects of a more conventional delivery of care by specialists

only

as

better for either themselves or their pa-tients. For this reason they were asked to identify statements describing advantages of specialist man-agement that would make specialist management

preferable to shared care.

Few areas in which specialist management held a clear advantage were identified. Of the total, 80% indicated that they did not feel any of the listed

advantages made specialist management the pre-ferred mode of medical care, 52% cited an advantage of the more traditional specialist care was that the time and effort required for communication be-tween the specialist and the primary care physician could be kept to a minimum, and 55% noted that

specialist management would ease their stress in administering potent drugs. Despite these advan-tages, the results previously given (Table 2) show that their time and effort were not excessive and participation did to some degree ease their concern about administering cancer chemotherapy. Further efforts in developing more efficient methods of com-munication and educational programs dealing with current cancer chemotherapeutic agents seem

in-dicated.

Of the total, 40% viewed as an advantage that specialist management transfers a patient with a high probability of dying from the practice of the primary care physician to the specialist. This rela-tively high percentage suggests an uneasiness many primary care physicians experience in dealing with patients with potentially fatal illnesses and

mdi-cates further need for physician education in this area.

One third of the physicians thought that

special-ist management would remove an economic liability

from the practice of the primary care physicians

although they had previously stated (Table 2) that care for these patients did not cause their practice to lose money.

One concern of the academic oncologists was that

once primary care physicians gained experience in treating these patients, they would prefer to manage them alone. Physicians were therefore asked to rank in order their preference for care if

shared-management were not available. Specialist manage-ment provided by academic oncologists was stated to be the preferred mode of care by 80% and none

listed

primary

physician care as the preferred mode; 20% would have chosen a local practicing oncologist if shared-management were not available.

Physicians were asked to rate their overall satis-faction with the program, whether they would agree to participate again, whether they would recom-mend participation in the program to a colleague, and whether they would accept the shared-manage-ment care system for patients diagnosed as having other, serious, noncancer illnesses. The responses were virtually unanimous to all four questions. All reported themselves to be very satisfied or satisfied, all would participate in the program again, all but

one would recommend the program to a colleague, and all would be willing to share in the treatment

of patients with other, serious noncancer ifinesses.

Given the strong positive responses of those

re-turning the questionnaire it seemed logical to con-sider whether those 34 who did not return the questionnaire might be biased to include physicians who were less satisfied with the program. In a

random sample telephone survey of eight physi-cians (23%) of the 34 nonrespondents, all eight indicated that they were satisfied or very satisifed with the program and would recommend it to a

Inward-WATS line to use in consulting with academic physicians

Protocols that are easier to follow and with clearer presentation of therapy plan More feedback on scope and medical impact

of shared-management care

Simpler single visit encounter form for use in recording and reporting on patient’s visit More educational assistance to the family

about the shared-management program and/or patient’s illness

Assignment of each shared-management pa-tient to specific academic physician at

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colleague. All but one of those contacted indicated that they would agree to participate again. The

exception was a

surgeon

who did not consider

chemotherapy an appropriate function for himself. As part of the overall program evaluation the physicians were asked for their recommendations for ways to improve the present shared-manage-ment program. Thirty-three of the physicians mdi-cated that an inward-WATS line for consulting with

the University of Iowa specialist would be a helpful change in the program. A report3 on the successful impact of direct telephone lines between specialists and primary care physicians in the management of patients supports this recommendation.

Twenty-two physicians stated that a helpful change would

be protocols and therapy plans that were easier to follow. Table 3 presents recommendations for changes in the program made by the 69 physicians.

SUMMARY

Physicians work for both economic and nonecon-omic rewards. Analysis of the motives for partici-pation in this shared-management approach to care indicates that primary care physicians are primarily motivated by the knowledge that they can facilitate the patient’s medical care and ease the family’s emotional and financial adjustments to the illness.

In cases where they perceive a conflict between the

patients’ and their own economic interests, the

phy-sicians in this program placed the patient and the family’s interest above their own. Participating phy-sicians reported that shared-management has pos-itively affected their professional development

be-cause it has enabled them to better care for the

patient and better understand the patient’s illness.

Specifically, they report that the program provides

them with personal satisfaction, an opportunity for

education, and a way to share the emotional load of

caring for these children. The participating primary

care physicians rejected any interest in caring for

these patients without input from academic oncol-ogists. Shared management thereby provides a

means whereby the therapeutic and scientific

ad-vantages of participation in clinical cancer trials can

be made available to all pediatric cancer patients

regardless

of their distance from the academic cen-ter.

ACKNOWLEDGMENTS

This investigation was supported by the National

In-stitutes of

Health and Research grant CA18139 from the National Cancer Institute.

The authors express appreciation to Drs Janco, Spe-yak, Strauss, Tannous, and the primary care physicians of Iowa, Illinois, and MissOUri whose cooperation and participation made this program and research possible.

REFERENCES

1. Kisker CT, Strayer FH, Wong KY, et al: Health outcomes of a community based therapy program for children with cancer-A shared-management approach. Pediatrics 66:900,

1980

2. Strayer FH, Kisker CT, Fethke CC: Cost effectiveness of the shared-management delivery system for children with can-cer. Pediatrics 66:907, 1980

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1981;67;833

Pediatrics

Faye H. Strayer, Carol C. Fethke, Thomas Kisker and Nancy G. Dekrey