Since the series of classic reports by the IOM (1
), consensus has been growing that health care is not realizing its full potential in the United States (1
). Cutting-edge advances in medicine appear in leading American journals on a regular basis, but the United States is ranked 13th in infant mortality and last among 19 industrialized nations in its ability to reduce mortality because of avoidable causes of death (3
). The only measure of health care where the United States leads is in cost per capita (5
). Although research has examined our system of care, it must be accelerated and focused to identify actionable improvements.
Critiques of the US health-care system emphasize the Nation's poor performance compared with other developed countries. One obvious factor is that 19.6% of the non-elderly adult population in the United States does not have health insurance at any given moment, and this affects their ability to obtain care (6
). Recommended improvements to the US health-care system have emphasized reducing costs of care and increasing insurance coverage. Creating a method of reimbursement that allows all citizens to receive care and aligns incentives and practices is critical to improving the health of Americans. However, the process of care for those who do have access also must be addressed to achieve high-quality outcomes (7
). The IOM reports on health care in general and cancer specifically make a strong case that health care in the United States is a fragmented and uncoordinated process that does not deliver the quality that is possible with what we know in medicine today (1
). Achieving improvements in care must therefore consider how to expand both the pool of people who have access to care and the process of care once they receive it.
The means forward to a successful approach to care is not entirely clear. Recognizing the limitations in the US health-care system, the IOM reports Crossing the Quality Chasm
and Ensuring Quality Cancer Care
identify six principles that must be the ultimate goal of systematic change to improve care. These principles are safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity (1
). The reports also note that no prescription exists for how to carry out such systematic change (1
). Since the IOM reports were published, many have considered this challenge (1
), and their work has led to a recognition that care is affected by multiple levels of influence.
The current health-care reform effort in the United States aims to ensure that the majority of people have access to a system of care in which they can obtain coverage regardless of employment and without fear of losing it if they become sick or unemployed. However, in Canada, where such a system of care has been in place for many years, the mere fact of having a system does not ensure that it delivers evidence-based care that meets the principles outlined by the IOM report. Canada ranks 15th out of 17 in infant mortality and 13th out of 18 among industrialized nations in its ability to reduce mortality because of avoidable causes of death (4
). To make progress in achieving the principles set out in the IOM report, we need to clarify how a health-care system can not only ensure coverage but also facilitate the process of care. Improvements have been demonstrated in breast cancer screening for ambulatory patients and myocardial infarction and pneumonia for hospitalized patients, but we need to address broader systematic changes across care in general. The entire spectrum of cancer care from screening end of life is a step in that direction. (12
In this supplement, we consider the process of cancer care from the perspective of the people responsible for providing that care, and we include insights from practitioners in Canada and the United States. We also include the perspectives of patients who are affected by the process. We define “process of cancer care” as the sum of the types of care, transitions, steps, and interfaces that must be traversed to receive health care across the cancer continuum (). Furthermore, we define “system of care” as one that not only provides coverage but also develops an infrastructure for communication that facilitates care delivery consistent with the IOM's six principles. Care across the cancer continuum encompasses different types of care, including risk assessment, detection, diagnosis, primary treatment, survivorship and surveillance, and end-of-life care () (10
Each of these types of care and the transitions between them involve steps that pose different challenges to individual patients, families, and physicians. For example, detection may occur through screening or testing following symptomatic presentation. Screening and symptomatic presentation each involve multiple steps that require coordination and a different balance of technical medical skills and logistical and emotional support. When detection of cervical abnormalities occurs by screening, for example, it often starts with a Papanicolaou test in primary care and repeated primary care visits to clarify the persistence of any abnormality. Persistent and/or severe abnormalities lead to a referral to an obstetrician/gynecologist because he or she has the expertise required to make the final diagnosis. Finding breast cancer through screening is different, however, because it involves an imaging technique that cannot be done by primary care physicians. Diagnosis of breast cancer may involve multiple steps, such as referral to a radiologist for further imaging or to a surgeon for a biopsy. Each visit is a step in screening or symptomatic detection, and every type of care involves multiple steps and interfaces.
Adding to the complexity of cancer care through these phases is the multiplicity of providers and institutions that are involved. At the beginning and end of the cancer continuum, most care involves primary care providers, whereas the care of subspecialists is central to diagnosis and treatment. After primary treatment is complete, care may move back and forth from primary care to subspecialty services if an abnormality arises or a nononcology problem needs attention. Toward the end of life, care may involve the oncologist and the primary care provider, as well as other organizations such as hospice. Central to the process of care across the continuum is the transfer of information and responsibility from one institution to another, from one physician to another, from physicians to staff, and from providers to patients and families. Providers and patients must share an understanding of the disease, the therapy, and its consequences, and they all must know who must do what and when. The exchange of information and responsibility is particularly important during transitions in care when new providers or care organizations become involved and new care decisions become necessary. Therefore, the interfaces of care and coordination among providers and institutions are critical to a successful process of cancer care. For example, studies of cancer have shown that whether people get screened accounts for a higher proportion of late-stage cancer than does the quality of the screening itself and that follow-up after an abnormal screen also is an important factor (14
shows the types of care and the triangles of communication that are established among cancer patients and their providers (16
). The communication triangles pose challenges for patients and physicians faced with coordinating care because sharing a common understanding about what actions are required and what they mean is often necessary to successfully manage the interfaces and transitions. This challenge is made more complex because community service providers, patients’ families, and physicians’ staff also are critical to care and create additional triangles of communication that challenge coordination. Note that also highlights that the patient is often the central repository of information. The fragmented system of independent practitioners and offices in the United States challenge easy communication and coordination among providers, thereby placing patients in the potentially awkward role of coordinating their care by default (17
The triangles of communication across the cancer continuum.