The Partnership Project Multidisciplinary video consultations between cancer patient, general practitioner and oncologist

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. BACKGROUND The 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. AIM The 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 life. AIM 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. METHOD The 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. RESULTS During 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 PERSPECTIVES The 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’.