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Physicians Involved in the Care of Patients with Recently

Diagnosed Cancer

CanCORS Provider Composition Writing Group

Academy Health Annual Research Meeting

Seattle, June 25, 2006

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CanCORS Provider Composition Writing Team

Katherine Kahn, MD 1,2

Nancy Keating, MD, MPH 3 Marybeth Landrum, PhD 3

John Ayanian, MD, MPP 3

Rob Boer, PhD 2

Carrie Klabunde, PhD 4

Paul Catalano, DSc 5

1 RAND, Santa Monica, CA; 2 University of California, Los Angeles, CA; 3 Harvard Medical School, Boston, MA; 4

National Cancer Institute, Bethesda, MD; 5 Dana Farber Cancer Institute, Boston, MA

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Why Study the Composition of the Physician Team Involved in

the Care of Cancer Patients?• Coordination of care and patient-

centeredness are two key attributes of quality– How should MD teams be structured?

• Performance measurement is moving toward physician-level accountability and reimbursement– Pay for performance

• Hypothesize disparities in team composition that if remedied could have important implications for care and outcomes downstream

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Study Questions

• How many physicians compose the team caring for patients with newly diagnosed cancer?

• How are primary care providers (PCPs) and cancer MDs involved overall, by disease, and by treatment?

• Which roles do they play?– How do physicians share roles?

• What patient and treatment characteristics predict physician team composition?

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Survey Methods• Surveyed patients 3-6 months after diagnosis• Queried patients about MD types and roles• Did they have:

– A primary care physician (PCP)?– A cancer MD?– At least one MD fulfilling key roles?

• Documented the name and address of each physician

• For each patient, linked patient and physician– Some physicians fulfill one and only one role– Other physicians fulfill multiple roles

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Primary Care Physician (PCP)

• “Some people have a primary care doctor.– This may be your family doctor, a general doctor, or

a specialist doctor.

• Sometimes your primary care doctor is someone who has known you for many years and sometimes it may be a doctor that your insurance company or health plan assigns to you who may not know you very well. – Do you have a primary care doctor?”

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Cancer Doctor

Doctor who did or is planning to treat you with:

• Surgery• Radiation• Chemotherapy

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Other Key Roles

• Decision making doctor: Who is the one doctor who has been most important in helping you to decide whether or not to have tests or treatments for your cancer?

• Doctor in charge of treatment: Who is the doctor that will be in charge of your cancer treatment for the next 6 months?

• Doctor who knows about symptoms: During the last 4 weeks, who is the one doctor who was most likely to know that you had a symptom or needed help for that problem?

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Mean Number of MDs Caring for Cancer

Patients

4.13.7

4.0

2.7

3.53.7

4.0

2.1

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Surgery Chemo Radiation No treatment

Mean #

of M

Ds

Lung cancer (n=3288) Colorectal cancer (n=4141)

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% Patients with PCP and Cancer MD Types

69%

80%

61%

77%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Lung cancer (n=3288) Colorectal cancer (n=4141)

Primary CareProvider

Cancer MD

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% Patients by Treatment

68% 67%72%

58%59% 56%62%

53%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Chemo Radiation Surgery None

88% 87% 85%

12%

84% 81% 79%

12%

Chemo Radiation Surgery None

With PCP With Cancer MD

Lung cancer (n=3288) Colorectal cancer (n=4141)

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% Patients with PCP and Cancer MD Types and

Roles

69%

80%89%

61%

77%68%

0%10%20%30%40%50%60%70%80%90%

100%

Lung cancer (n=3288) Colorectal cancer (n=4141)

PCP > 1 key role*Cancer MD

*Key roles include: MD most important in helping with decision; MD in charge of treatment for the next 6 months; MD most likely to know symptoms

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MD Types Fulfilling Key Roles by MD Type on Patient Care

Team (n=7429)

MD fulfilling key role4

Types of MD on Team:

PCP1

(7%)

Cancer MD2

(20%)

Both3

(48%)

Neither(15%)

PCP 59% -- 40% --Cancer MD -- 43% 37% --Other MD 28% 43% 8% 24%No key role fulfilled

13% 14% 14% 76%1 PCP= PCP and No Cancer MD; 2 Cancer MD=Cancer MD and No PCP; 3 Both= PCP and Ca MD 4Key role defined as: MD most important in helping with decision; MD in charge of treatment for the next 6 months; MD most likely to know symptoms

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Key Roles * Fulfilled for Patients with PCPs by

Treatment

0%10%20%30%40%50%60%70%80%90%

100%

Chemo Radiation Surgery Notreatment

*Key roles include: MD most important in helping with decision; MD in charge of treatment for the next 6 months; MD most likely to know symptoms

PCP also fulfills role as:

Cancer MD Cancer MD and also > one key role > one other key role ( cancer MD) No other roles (PCP only)

27% 32% 42%440 60%

69% 65% 56% 40%

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Odds Ratio Predicting Pts with MD Types/Roles

PCP 65%

Any Key role79%

PCP fulfills any key role

Age 1.0 1.0 1.0

Medicaid 0.4 0.5 1.4

No insurance 0.3 0.3 1.1

High school grad 0.8 0.8 0.7

Some college 0.9 0.7 1.2

College grad 1.0 1.2 1.0

> College grad 1.0 0.8 1.0

Hispanic English language

0.8 0.9 1.2

Hispanic Spanish language

0.4 0.6 1.9

Black 1.2 1.5 1.4

Asian 1.0 1.2 1.5

>1 Race 1.1 1.3 1.9Logistic regression also adjusted for: gender, study site, survey type, treatment, and cancer MD

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Conclusions• Within the first 4 months after a diagnosis of

lung and colorectal cancer, the management of patients with incident cancer typically includes several physicians including both primary-care and cancer physicians.

• While specialty type is clearly defined in the health care system, – Role fulfillment is fluid across specialty

types and – Varies by disease, treatment, and patient

characteristics

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Conclusions• These findings underscore the need to better

understand roles physicians play in the management of patients with complex diseases such as cancer.– How do these multiple physicians on a team interact with

the patient about important interventions?– How are efforts by different MD types coordinated within

patient?

• As hypothesized, we note patient demographics significantly predict the composition of physician teams. – This may represent an opportunity to intervene in care

early to avoid down the line disparities in care and outcomes

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Policy Implications and Next Steps

• These findings also reveal complexities likely to be associated with:– the identification of a single MD responsible for

performance defining quality care and – financial incentives defined by protocols

specifying the attribution of complex care to individual MDs

• Next steps-Examination of the effects of: – Hospitals, systems, and MD style of care on team

compositions– Team composition on processes and outcomes of

care.