In the final analysis, the coordination of end-of-life care between primary care physicians and oncologists is an important issue only insofar as it affects the quality of care that is delivered. As evidenced by recent literature syntheses (4
) and a report by the Institute of Medicine (1
), experts widely agree that coordination of care—conceived broadly—is a key factor influencing the quality of palliative and end-of-life care for cancer patients. However, as noted by the Institute of Medicine (1
), no widely accepted indicators or measures of care coordination currently exist, and only a small number of studies have provided weak evidence that interventions to improve care coordination improve care outcomes for cancer patients at the end of life (4
Data are particularly lacking on the nature and outcomes of care coordination occurring specifically between primary care physicians and oncologists. Limited data suggest only indirectly that care coordination affects important patient outcomes. For example, Jones et al. (31
) observed a statistically significant lower risk of death among 329 patients with lung cancer if they had one or more primary care visits in the first 6 months after cancer diagnosis compared with those who did not use primary care. This study observed median survival times of 3.7 vs 7.5, 13.9, and 13.8 months for those with zero, one, two, and three primary care contacts, respectively (P
< .0001). However, these primary care visits may have been devoted to addressing problems that had little or nothing to do with patients’ cancer or the coordination of cancer care. The study did not examine key variables including the extent of care coordination between primary care and oncology specialists. Furthermore, although a few outcomes studies have examined “coordination” and “continuity” with respect to the provision of particular services (eg, home care, hospice, and nursing support) or information to cancer patients at the end of life (30
), care coordination specifically between primary care and oncology physicians has not been examined. This is a critical gap in our knowledge, given that each of these physicians might legitimately “lay claim” to care responsibilities in these domains, and differences in their perspectives and skills may influence the quality of care provided.
In this respect, the few data that are available do shed light on potential ways in which the coordination of care between primary care physicians and oncologists might affect the quality of end-of-life care in cancer patients. In an observational study of advanced breast cancer patients tracked by the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, Keating et al. (33
) examined predictors of hospice use and enrollment at the end of life. In multivariate analyses adjusting for patient characteristics, hospice referral rates differed significantly according to the physicians seen by the patient: 41% for patients seeing both a cancer specialist and a primary care physician, 38% for patients seeing a cancer specialist and no primary care physician, and 30% among those seeing a primary care physician and no cancer specialist. The finding of higher rates of hospice referral for oncology specialists than for primary care physicians is consistent with another study by Keating et al. (34
) and may suggest a greater propensity or capacity of oncologists to use palliative and end-of-life care services or to recognize the appropriateness of such services (33
). However, some studies have shown no specialty-specific differences in hospice referral rates (35
), and others have shown longer survival time for hospice patients referred by primary care vs oncology physicians (36
). Other studies have identified specialty-specific attitudinal differences that may moderate the effect of physician specialty on hospice referral patterns, including more favorable attitudes toward hospice care (37
), longer lead-time preference for hospice referral (38
), and more pessimistic estimates of prognosis (39
) for primary care than for oncology physicians.
Important unmeasured variables in all of these studies include the nature and extent of interaction between primary care and oncology physicians. Primary care physicians may bring different preferences and skills to bear in end-of-life care, and their concurrent involvement may have interactive effects on care quality. In this regard, the finding by Keating et al. (33
) that patients seeing both an oncologist and a primary care physician had the highest hospice referral rate is intriguing and may suggest some beneficial influence of care coordination or of the involvement of greater numbers of physicians in decision making at the end of life.
Similarly, it is possible that coordination and continuity of care may affect utilization of other important clinical services at the end of life. Burge et al. (40
) examined correlates of continuity of end-of-life care for metastatic cancer patients provided by family physicians in Nova Scotia, Canada, an area in which the bulk of such care is provided by family physicians. In this retrospective population-based study, continuity of care (operationalized in terms of the proportion of patient visits to a single vs multiple providers) was strongly associated with lower emergency department utilization at the end of life. The relationship between care continuity and intensive care unit utilization was examined by Sharma et al. (41
), who used the SEER-Medicare database to study end-of-life hospital care received by advanced lung cancer patients in the United States. In this study, continuity of care—operationalized in terms of whether patients were seen by their usual care provider during their final recorded hospitalization—was associated with a 25% reduced odds of entering the intensive care unit. The potential influence of care continuity on end-of-life health services utilization was also examined by Barbera et al. (12
) in Canada. Their study found that patients who received home care within 6 months of death, or a palliative care assessment or family physician home visit within 2 weeks of death, had a significant reduction in the odds of receiving poor quality of care at the end of life—indicated by a reduction in intensive care admissions, emergency department visits, and receipt of chemotherapy.
Although these findings may be difficult to generalize to other care settings, they suggest that continuity of care may have important effects on the use of important health services at the end of life.
Cancer care in the nursing home setting is an informational black hole. No good data exist. Quality of care measures in traditional care and nursing home care don’t match. Many cancers are diagnosed after admittance to a nursing home. Everything is different in the nursing home setting: no primary care providers, no multidisciplinary care teams. Care is provided by the nursing home staff, and 50 percent of nursing homes currently have unfilled medical director positions.
From a Supplement Author
Some important unanswered questions, however, are whether these same potential effects apply equally to continuity of care provided by oncologists and primary care physicians in other settings, and how “discontinuity” posed by concurrent visits to both oncologists and primary care physicians in other settings might also influence the use of various health services.
A few other small studies have compared primary care and oncology physicians in terms of specific end-of-life care practices, such as pain management. Older studies of care delivered in home hospice settings have suggested that oncologists are more aggressive than primary care physicians in prescribing opioids for pain control (42
). Corroborating the generalizability of these findings, a survey of French oncology and primary care physicians found that primary care physicians were less satisfied with their ability to manage pain and more reluctant to prescribe morphine for pain control (44
). A more recent survey (45
), however, found that although French primary care physicians were more likely than oncologists to equate high-dose morphine therapy with euthanasia, they did not report lower morphine prescribing in general. These types of studies have not been replicated in Canada or the United States, where the rate of opioid prescribing in general and by primary care physicians has been increasing recently (46
), but they raise the possibility that involvement of oncology physicians may foster greater use of opioids for pain control in cancer patients at the end of life. These trends further heighten the need for care coordination and communication because opioids are legally controlled substances requiring careful monitoring and management and for which individual physicians typically assume prescribing responsibility.
Clearly, much remains unknown about the determinants and outcomes of care coordination and continuity in end-of-life care. Further research examining best practices, communication tools, patient experiences with care, cost effectiveness, and health-related quality of life in relation to the integration of primary and oncology care will be required to meet escalating demands for quality end-of-life care for patients with advanced cancer.