Development and implementation of “advanced cancer shared care letters” to improve shared care between oncologists and family physicians.

Abstract

37 Background: Optimal care of patients living with advanced cancer requires a collaborative approach between oncologists and family physicians (FPs), starting early in the disease trajectory. We developed and implemented “advanced cancer shared care letters” to improve communication, collaboration and role clarity amongst providers. Methods: A physician-to-physician standardized “advanced cancer shared care letter” for colorectal cancer was created at a Canadian tertiary cancer center with input across stakeholders. The letter is ordered by the oncologist when they determine a patient to have advanced (i.e. incurable) cancer. The letter outlines components of shared care, division of responsibilities, monitoring for complications, responding to oncological emergencies, and consultation services such as palliative care. A cover sheet is provided for FPs to return to confirm their involvement, indicate their comfort level with providing a palliative approach to care (e.g. advance care planning, managing symptoms) and ask questions. Letters were piloted in two gastrointestinal (GI) oncology outpatient clinics for two months, and then implemented in the seven remaining GI clinics over two months. Metrics were collected for five months to evaluate implementation. Results: Over 5 months, 76 shared care letters were ordered; in 5 cases, no FP was identifiable. Cover sheets were returned by 39/71 FPs (55%). Content returned included prognosis questions, goals of care conversations, supportive services available in their practice and those in use by the patient, capacity to manage symptoms (e.g. opioid prescribing), and requests to engage palliative care services. Implementation challenges included frequent change in clerical staff and management, electronic chart challenges and variable adoption. Conclusions: The shared care letter provides a useful mechanism for FPs and oncologists to share information. It increases communication and care coordination between typically siloed providers, to enhance patient experience. A similar letter is provided to patients and we are now developing a shared care letter that is generalizable for any type of advanced cancer.

What helps or hinders the communication of poor prognosis between secondary and primary care? A systematic review with narrative synthesis

“…The sharing of information about poor prognosis was described in a range of ways including written information following outpatient clinics,(17,19,24,25,32,33,42) discharge summaries,(22,24-26,31) shared electronic records,(23) telephone(26,40,42) and face-toface handover. (26) Two studies evaluated interventions designed for sharing poor prognosis information; (28,44) two others evaluated standardised interventions for shared carebetween oncologists and GPs (18,45).…”

“…) The GPs and oncology specialists participating in a Dutch study of medium quality, mentioned that it was often difficult to contact each other by telephone because of limited availability (42). Standardised written interventionsTwo studies report low-medium quality evidence on standardised, written interventions for facilitating shared care between oncologists and GPs (18,45). Both studies described the sharing of prognosis as one element of the overall intervention, but neither reported on how this particular information had been provided by the oncologist or on how this had impacted on patient care.Poor prognosis letterThe Poor Prognosis Letter (PPL) was developed to be sent by the secondary care team to the GP when discharging patients thought to be in the last year of their life.…”

“…A complex intervention of medium quality, designed to improve interprofessional collaboration, led to better perceptions of collaboration by both patients and family physicians, as well as decreased hospital admissions and Emergency Department attendances. (18) Watanabe et al(45) reported in a conference abstract (low quality evidence) the outcomes of a standardised shared care letter for patients with colorectal cancer, concluding that the letter increased communication and care coordination, although the full study results were not published. Another conference abstract, of medium quality, reported the findings of a local audit of poor prognosis letters (PPLs) sent to GPs by surgical teams.…”