Many immigrant populations lack access to primary health care. A recently published study on cholesterol screening among immigrant populations in the US found disparities in cholesterol screening in those originating from Mexico, largely due to limited access to healthcare. This inverse care affects immigrants in many destination countries despite their greater health need.

Please see related article: http://www.equityhealthj.com/content/11/1/22

Objectives

To investigate key patient clinical and demographic characteristics associated with time between colonoscopy and surgery, and choice of treatment centre for colorectal cancer (CRC) patients. This will add to the little published research examining the pathway following CRC diagnosis and prior to surgery.

Design

Retrospective cohort analysis of linked data.

Setting

A population-based sample of people diagnosed August 2004 to December 2007 in New South Wales, Australia.

Participants

569 CRC patients, of whom 407 (72%, 95% CI 68% to 75%) had colonoscopy followed by surgery.

Primary outcome measures

Time between colonoscopy and surgery, and whether the surgery took place in a specialist cancer centre.

Results

Among the 407 eligible patients analysed, the median time from colonoscopy to surgery was 19 days (IQR 12–29 days). After adjusting for key demographic and clinical characteristics such as age and disease stage, the time was longer for rectal cancer patients and those reporting fair/poor health, although differences in medians were <5 days. 24% (95% CI 20% to 28%) had surgery in a specialist cancer centre, which was more common among people resident in metropolitan areas (37% vs 14% for others, adjusted p=0.001) and those without private health insurance (30% vs 21% for others, adjusted p=0.03).

Conclusions

There do not appear to be systemic issues affecting time from colonoscopy to surgery related to patients' socio-demographic characteristics. However, patients with private insurance and those living in rural areas may be less likely to receive optimal specialist treatment. A more systematic approach might be needed to ensure cancer patients are treated in specialist cancer centres, particularly patients requiring more specialised treatment.

Article summary

Article focus

Investigate key patient clinical and demographic characteristics associated with time between colonoscopy and surgery, and choice of treatment centre for colorectal cancer patients in New South Wales, Australia.

Most existing research has focused on delay prior to diagnosis, and little is known about factors associated with referral to specialist treatment following diagnosis.

Key messages

Rectal cancer cases had slightly longer time to surgery than colon cancer cases.

Treatment in a specialist cancer centre was associated more with patient access than disease characteristics.

We need to ensure that those with the greatest need, such as those with rectal cancer, have access to timely and specialist treatment.

Strengths and limitations of this study

This is one of the first studies to examine the pathway following colorectal cancer diagnosis and prior to surgery, with a relatively large population-based sample of patients.

Surgery was the only treatment we could reliably analyse.

Surgeon specialties were not known so specialist centres were identified as institutions with radiotherapy facilities.

We cannot determine the exact reason for longer time to treatment and it might actually be a positive, possibly reflecting referral to a specialist surgeon or preoperative radiotherapy.

Background

Ongoing care for chronic conditions such as diabetes is best provided by a range of health professionals working together. There are challenges in achieving this where collaboration crosses organisational and sector boundaries. The aim of this article is to explore the influence of power dynamics and trust on collaboration between health professionals involved in the management of diabetes and their impact on patient experiences.

Methods

A qualitative case study conducted in a rural city in Australia. Forty five health service providers from nineteen organisations (including fee-for-service practices and block funded public sector services) and eight patients from two services were purposively recruited. Data was collected through semi-structured interviews that were audio-taped and transcribed. A thematic analysis approach was used using a two-level coding scheme and cross-case comparisons.

Results

Three themes emerged in relation to power dynamics between health professionals: their use of power to protect their autonomy, power dynamics between private and public sector providers, and reducing their dependency on other health professionals to maintain their power. Despite the intention of government policies to support more shared decision-making, there is little evidence that this is happening. The major trust themes related to role perceptions, demonstrated competence, and the importance of good communication for the development of trust over time. The interaction between trust and role perceptions went beyond understanding each other's roles and professional identity. The level of trust related to the acceptance of each other's roles. The delivery of primary and community-based health services that crosses organisational boundaries adds a layer of complexity to interprofessional relationships. The roles of and role boundaries between and within professional groups and services are changing. The uncertainty and vulnerability associated with these changes has affected the level of trust and mistrust.

Conclusions

Collaboration across organisational boundaries remains challenging. Power dynamics and trust affect the strategic choices made by each health professional about whether to collaborate, with whom, and to what level. These decisions directly influenced patient experiences. Unlike the difficulties in shifting the balance of power in interprofessional relationships, trust and respect can be fostered through a mix of interventions aimed at building personal relationships and establishing agreed rules that govern collaborative care and that are perceived as fair.