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
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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2
Why Study the Composition of the
Physician Team Involved in the Care
of Cancer Patients?
• Coordination of care and patientcenteredness 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
3
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?
4
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
Lung cancer (n=3288)
4.5
Mean # of MDs
4
3.5
4.1
3.5
3.7 3.7
Colorectal cancer (n=4141)
4.0 4.0
3
2.7
2.5
2.1
2
1.5
1
0.5
0
Surgery
Chemo
Radiation
No treatment
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% Patients with PCP and
Cancer MD Types
Lung cancer (n=3288)
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Colorectal cancer (n=4141)
80% 77%
69%
61%
Primary Care
Provider
Cancer MD
10
% Patients by Treatment
Lung cancer (n=3288)
Colorectal cancer (n=4141)
With PCP
With Cancer MD
100%
88%
90%
80%
70%
60%
68%
87%
81%
72%
67%
59%
84%
56%
62%
58%
85%
79%
53%
50%
40%
30%
20%
12% 12%
10%
0%
Chemo
Radiation
Surgery
None
Chemo
Radiation
Surgery
None
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% Patients with PCP and
Cancer MD Types and Roles
Lung cancer (n=3288)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Colorectal cancer (n=4141)
89%
69%
80% 77%
68%
61%
PCP
Cancer MD
> 1 key role*
*Key roles include: MD most important in helping with decision; MD in charge
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of treatment for the next 6 months; MD most likely to know symptoms
MD Types Fulfilling Key Roles by
MD Type on Patient Care Team
(n=7429)
MD fulfilling
key role4
PCP1
(7%)
(20%)
(48%)
(15%)
PCP
59%
-28%
13%
-43%
43%
14%
40%
37%
8%
14%
--24%
76%
Cancer MD
Other MD
No key role
fulfilled
1
Types of MD on Team:
Cancer MD2
Both3
PCP= PCP and No Cancer MD;
4Key
2
Neither
Cancer MD=Cancer MD and No PCP; 3 Both= PCP and Ca MD
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
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
27%
69%
Chemo
32%
42%440
65%
56%
Radiation
Surgery
60%
40%
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)
No
treatment
*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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Odds Ratio Predicting Pts with MD Types/Roles
PCP
65%
Any Key role
79%
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
1.9
Logistic 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.
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