TY - GEN
T1 - The Partnership Project Multidisciplinary video consultations between cancer patient, general practitioner and oncologist
AU - Trabjerg, Theis
PY - 2020
Y1 - 2020
N2 - This PhD thesis is based on four papers, all published or submitted for publication in
international peer‐review scientific journals. The thesis describes the development,
feasibility, process evaluation of the Partnership Project, and between‐groups analysisfor the
GP evaluation. The Partnership Project is a collaboration between the Research Unit for
General Practice, University of Southern Denmark and the Department of Oncology, Lillebaelt
University Hospital, Vejle Hospital. BACKGROUNDThe health care system is facing a growing number of cancer patients. Early detection of
cancer and better treatment has led to a growing number of cancer survivors. However, the
world is faced by a shortage of health care workers to accommodate the increase. Therefore,
interprofessional collaborative practice is considered essential for the delivery of safe,
effective and coordinated health care. The World Health Organization has requested that
interprofessional learning and collaborative practice should be essential for the health care
systems of the future. Furthermore, international and national guidelines have recommended
that general practitioners should play a central role as coordinators of cancer patient
trajectories and be more involved in supporting cancer patients. However, cancer follow‐up
and rehabilitation still pose considerable problems for general practitioners during and
following long‐term hospital‐based cancer treatment. To enhance the chances of inter‐profession learning, cancer rehabilitation and supporting the
patient in navigating coordination of their care, we propose a novel approach in which we
bring the cancer patient, oncologist and general practitioner together using video
consultations.
AIMThe overall aim of the Partnership Project was to develop and investigate this new
intervention bringing cancer patient, general practitioner and oncologist together in a joint
video‐based consultation. In this thesis, I evaluate the Partnership Project in five studies: development of the
intervention, feasibility and process analysis, explore the intervention, evaluate user
perspectives from the intervention group in the randomised controlled trial and between‐
groups analysis of the GP evaluation in the randomised design.AIM OF STUDY 1 (PAPER 1)To develop the Partnership Intervention bringing the oncologist and GP together with the
cancer patient in a single joint video‐based consultation in the early months of oncology
treatment, and to design a randomised controlled trial testing the effect of this intervention
on the perception of cancer patients of inter‐sector cooperation, continuity of cancer care,
distress and health‐related quality of lifeAIM OF STUDY 2 To analyse the process of enrolment by investigating the acceptability and feasibility of the
intervention. AIM OF STUDY 3 (PAPER 2)To make a process evaluation, evaluating the consultation structure, the health concerns
presented and patient‐centeredness when two doctors are attending consultations through
video with a cancer patient present at the office of the oncologist or GP. AIM OF STUDY 4 (PAPER 3)To make a process evaluation, evaluating key elements of user perspectives on the trial
intervention: Continuity, patient involvement, sharing of knowledge between health
professionals and technical quality. AIM OF STUDY 5 (PAPER 4)To analyse, the effects on GP perceived involvement in cancer care and their satisfaction with
the cross‐sectoral information and coordination of care, based on results from the
randomised controlled trial. METHODThe following describes the method used for the five studies.1: Describes the development of the pragmatic randomised controlled trial, which evaluates
the intervention using patient‐reported outcome measures on inter‐sector cooperation
(primary outcome), health‐related quality of life, satisfaction with information provided
during treatment, illness intrusiveness and psychological well‐being using depression and
anxiety scores. 2: The pilot study completed in the spring of 2016 examined previously identified key
uncertainties to support the refinement of the study design. Piloting contributed to the
further development of the intervention, test of outcomes measures and feasibility of the
study. The pilot consists of ten video consultations with colorectal cancer patients, their
general practitioner and four different oncologists at the Oncology Department, Lillebaelt
University Hospital. 3: A qualitative evaluation of recordings of twelve video consultations. By using the
Framework Method to draw conclusions based on themes derived from the recordings.
Thereby investigating the structure, content and benefits of multidisciplinary video
consultations. 4: Evaluates user perspectives from the participating patients, general practitioners and
oncologists in the intervention group. Data is derived from survey data presented to the
participants directly after the video consultation. Furthermore, the study discussesthe quality
of video consultations, along with time consumption and logistical challenges. 5: Investigates GPs perception of information and cooperation after the addition of a shared
video consultation with the patient, oncologist and general practitioners compared to usual
communication through written summary letters. Data is derived from the four‐month
follow‐up survey to GPs in the randomised controlled design. The survey comprised of
measuring the numbers of patient visits in the follow‐up period and 28 items divided into five
themes; GP assessment of the contact between the Hospital, information from the Hospital
to the GP, GP own involvement in the trajectory, information from the Hospital to help the
GP and GP satisfaction with the distribution of task and roles.RESULTSDuring the pilot test of the randomised controlled trial, we investigated the logistical issues
concerning the trial. We found that the trial should be as pragmatic and close to routine
clinical life as possible. The randomised trial finish inclusion in November 2019 and the final
video consultation was completed in February 2020. Follow‐up for GPs was completed in April
2020, and the last data from the seven months follow for patients is accomplished in August
2020. The qualitative study consists of recordings retrieved between October 2018
and February 2019 of twelve consultations with twelve 36 to 71‐year‐old cancer patients.
During the qualitative analyses of the consultations, we identified fifteen themes and grouped
them into three categories: The implication of sharing a consultation, consultation structure
and the content of the consultation.Data for the user perspective trial was obtained from the start of the study in
June 2016 until 15 April 2019. At that time, 174 patients were enrolled in the Partnership
Project, including 87 (50%) randomly allocated to the intervention group. Of the 87
randomised patients, 62 cases could potentially have completed the consultation. However,
in seven (11%) cases, video equipment failures caused cancellation, and two were conducted
with audio‐only. The response rates for the user experience surveys from patients, GPs and
oncologists were 80%, 71% and 100% respectively. The mean duration of all the consultations
was 15 minutes (SD = 3.9, CI = 14.0‐16.0). Patients became more aware of the role of the
oncologists and GPsin the trajectory in 91% and 86% of consultationsrespectively. Moreover,
93% of the patients became more confident in whom to contact with a given problem.
Regarding ‘satisfaction’, 95% believed it was helpful to have a consultation with both
oncologist and GP. Oncologists believed that 86% of the consultations contributed to a more
coherent trajectory for the patient and deemed useful in 76% of the cases. A total of 90% of
the GPsfound that the consultation could give a more coherent course for the patient. In 69%
of the cases, the consultation helped to clarify their role during the trajectory.Data from the between‐groups GP evaluation was obtained from the start of the
study in June 2016 until the final inclusion of patients in November 2019 and the subsequent
four‐month follow‐up from GPs in April 2020. In total, 281 patients were included in the
randomised trial. A total of 124 (44%) questionnaires were returned from 105 unique GPs, eight having patients in both groups. Since 22 GPs (16%) with patients in the intervention
group did not wish to participate, the overall response rate for GPs was 48%. The regression
analysis showed statistically significant odds ratio in favour of the intervention regarding the
item "As a GP, did you experience direct contact or dialogue with the Department of
Oncology" (OR 6.95 (CI:2.96, 16.35)) and the item "As a GP, how satisfied are you, with the
distribution of tasks and roles regarding initiatives practice could initiate concerning the
patient trajectory" (OR 3.03 (CI:1.35, 6.82)). OR was significant and in the same direction for
both intention‐to‐treat and per‐protocol analysis. CONCLUSION AND PERSPECTIVESThe Partnership Project is the first to investigate consultations bringing a cancer patient in
ongoing oncology treatment together with the oncology specialist and GP in a cross‐sector,
multidisciplinary video consultation.The thesisshowsthat when successfully setting up a joint video consultation, the participants
acted in a patient‐centred manner and with high user satisfaction. Furthermore, the
timeframe remained within that of a standard clinical consultation in general practice (15
minutes), clarifying tasks and responsibility between doctors.
Overall, video consultations contribute to a more coherent cancer trajectory. During development, it became clear how new and innovative the project is both regarding
the scientific approach with cross‐sector consultation with a patient but also regarding the
technical problems.Comparison of the intervention and control group for patients within the randomised design
is an important next step before a decision can be made about implementation. Trials,
including other cancer hospitals and other patient groups, are essential for fully
understanding the generalisability and usefulness of the intervention in other settings.
Economic evaluation could also contribute to the question ‘was it worth the time’.
AB - This PhD thesis is based on four papers, all published or submitted for publication in
international peer‐review scientific journals. The thesis describes the development,
feasibility, process evaluation of the Partnership Project, and between‐groups analysisfor the
GP evaluation. The Partnership Project is a collaboration between the Research Unit for
General Practice, University of Southern Denmark and the Department of Oncology, Lillebaelt
University Hospital, Vejle Hospital. BACKGROUNDThe health care system is facing a growing number of cancer patients. Early detection of
cancer and better treatment has led to a growing number of cancer survivors. However, the
world is faced by a shortage of health care workers to accommodate the increase. Therefore,
interprofessional collaborative practice is considered essential for the delivery of safe,
effective and coordinated health care. The World Health Organization has requested that
interprofessional learning and collaborative practice should be essential for the health care
systems of the future. Furthermore, international and national guidelines have recommended
that general practitioners should play a central role as coordinators of cancer patient
trajectories and be more involved in supporting cancer patients. However, cancer follow‐up
and rehabilitation still pose considerable problems for general practitioners during and
following long‐term hospital‐based cancer treatment. To enhance the chances of inter‐profession learning, cancer rehabilitation and supporting the
patient in navigating coordination of their care, we propose a novel approach in which we
bring the cancer patient, oncologist and general practitioner together using video
consultations.
AIMThe overall aim of the Partnership Project was to develop and investigate this new
intervention bringing cancer patient, general practitioner and oncologist together in a joint
video‐based consultation. In this thesis, I evaluate the Partnership Project in five studies: development of the
intervention, feasibility and process analysis, explore the intervention, evaluate user
perspectives from the intervention group in the randomised controlled trial and between‐
groups analysis of the GP evaluation in the randomised design.AIM OF STUDY 1 (PAPER 1)To develop the Partnership Intervention bringing the oncologist and GP together with the
cancer patient in a single joint video‐based consultation in the early months of oncology
treatment, and to design a randomised controlled trial testing the effect of this intervention
on the perception of cancer patients of inter‐sector cooperation, continuity of cancer care,
distress and health‐related quality of lifeAIM OF STUDY 2 To analyse the process of enrolment by investigating the acceptability and feasibility of the
intervention. AIM OF STUDY 3 (PAPER 2)To make a process evaluation, evaluating the consultation structure, the health concerns
presented and patient‐centeredness when two doctors are attending consultations through
video with a cancer patient present at the office of the oncologist or GP. AIM OF STUDY 4 (PAPER 3)To make a process evaluation, evaluating key elements of user perspectives on the trial
intervention: Continuity, patient involvement, sharing of knowledge between health
professionals and technical quality. AIM OF STUDY 5 (PAPER 4)To analyse, the effects on GP perceived involvement in cancer care and their satisfaction with
the cross‐sectoral information and coordination of care, based on results from the
randomised controlled trial. METHODThe following describes the method used for the five studies.1: Describes the development of the pragmatic randomised controlled trial, which evaluates
the intervention using patient‐reported outcome measures on inter‐sector cooperation
(primary outcome), health‐related quality of life, satisfaction with information provided
during treatment, illness intrusiveness and psychological well‐being using depression and
anxiety scores. 2: The pilot study completed in the spring of 2016 examined previously identified key
uncertainties to support the refinement of the study design. Piloting contributed to the
further development of the intervention, test of outcomes measures and feasibility of the
study. The pilot consists of ten video consultations with colorectal cancer patients, their
general practitioner and four different oncologists at the Oncology Department, Lillebaelt
University Hospital. 3: A qualitative evaluation of recordings of twelve video consultations. By using the
Framework Method to draw conclusions based on themes derived from the recordings.
Thereby investigating the structure, content and benefits of multidisciplinary video
consultations. 4: Evaluates user perspectives from the participating patients, general practitioners and
oncologists in the intervention group. Data is derived from survey data presented to the
participants directly after the video consultation. Furthermore, the study discussesthe quality
of video consultations, along with time consumption and logistical challenges. 5: Investigates GPs perception of information and cooperation after the addition of a shared
video consultation with the patient, oncologist and general practitioners compared to usual
communication through written summary letters. Data is derived from the four‐month
follow‐up survey to GPs in the randomised controlled design. The survey comprised of
measuring the numbers of patient visits in the follow‐up period and 28 items divided into five
themes; GP assessment of the contact between the Hospital, information from the Hospital
to the GP, GP own involvement in the trajectory, information from the Hospital to help the
GP and GP satisfaction with the distribution of task and roles.RESULTSDuring the pilot test of the randomised controlled trial, we investigated the logistical issues
concerning the trial. We found that the trial should be as pragmatic and close to routine
clinical life as possible. The randomised trial finish inclusion in November 2019 and the final
video consultation was completed in February 2020. Follow‐up for GPs was completed in April
2020, and the last data from the seven months follow for patients is accomplished in August
2020. The qualitative study consists of recordings retrieved between October 2018
and February 2019 of twelve consultations with twelve 36 to 71‐year‐old cancer patients.
During the qualitative analyses of the consultations, we identified fifteen themes and grouped
them into three categories: The implication of sharing a consultation, consultation structure
and the content of the consultation.Data for the user perspective trial was obtained from the start of the study in
June 2016 until 15 April 2019. At that time, 174 patients were enrolled in the Partnership
Project, including 87 (50%) randomly allocated to the intervention group. Of the 87
randomised patients, 62 cases could potentially have completed the consultation. However,
in seven (11%) cases, video equipment failures caused cancellation, and two were conducted
with audio‐only. The response rates for the user experience surveys from patients, GPs and
oncologists were 80%, 71% and 100% respectively. The mean duration of all the consultations
was 15 minutes (SD = 3.9, CI = 14.0‐16.0). Patients became more aware of the role of the
oncologists and GPsin the trajectory in 91% and 86% of consultationsrespectively. Moreover,
93% of the patients became more confident in whom to contact with a given problem.
Regarding ‘satisfaction’, 95% believed it was helpful to have a consultation with both
oncologist and GP. Oncologists believed that 86% of the consultations contributed to a more
coherent trajectory for the patient and deemed useful in 76% of the cases. A total of 90% of
the GPsfound that the consultation could give a more coherent course for the patient. In 69%
of the cases, the consultation helped to clarify their role during the trajectory.Data from the between‐groups GP evaluation was obtained from the start of the
study in June 2016 until the final inclusion of patients in November 2019 and the subsequent
four‐month follow‐up from GPs in April 2020. In total, 281 patients were included in the
randomised trial. A total of 124 (44%) questionnaires were returned from 105 unique GPs, eight having patients in both groups. Since 22 GPs (16%) with patients in the intervention
group did not wish to participate, the overall response rate for GPs was 48%. The regression
analysis showed statistically significant odds ratio in favour of the intervention regarding the
item "As a GP, did you experience direct contact or dialogue with the Department of
Oncology" (OR 6.95 (CI:2.96, 16.35)) and the item "As a GP, how satisfied are you, with the
distribution of tasks and roles regarding initiatives practice could initiate concerning the
patient trajectory" (OR 3.03 (CI:1.35, 6.82)). OR was significant and in the same direction for
both intention‐to‐treat and per‐protocol analysis. CONCLUSION AND PERSPECTIVESThe Partnership Project is the first to investigate consultations bringing a cancer patient in
ongoing oncology treatment together with the oncology specialist and GP in a cross‐sector,
multidisciplinary video consultation.The thesisshowsthat when successfully setting up a joint video consultation, the participants
acted in a patient‐centred manner and with high user satisfaction. Furthermore, the
timeframe remained within that of a standard clinical consultation in general practice (15
minutes), clarifying tasks and responsibility between doctors.
Overall, video consultations contribute to a more coherent cancer trajectory. During development, it became clear how new and innovative the project is both regarding
the scientific approach with cross‐sector consultation with a patient but also regarding the
technical problems.Comparison of the intervention and control group for patients within the randomised design
is an important next step before a decision can be made about implementation. Trials,
including other cancer hospitals and other patient groups, are essential for fully
understanding the generalisability and usefulness of the intervention in other settings.
Economic evaluation could also contribute to the question ‘was it worth the time’.
KW - Almen praksis
KW - Cancer
KW - Videosamtale
KW - Tværsektorielt samarbejde
KW - Onkologi
U2 - 10.21996/0s2e-eq52
DO - 10.21996/0s2e-eq52
M3 - Ph.D. thesis
PB - Syddansk Universitet. Det Sundhedsvidenskabelige Fakultet
ER -