Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Women with breast cancer were more satisfied with general practitioner care than with outpatient clinic care

PDF

ACP J Club. 2000 May-June;132:106. doi:10.7326/ACPJC-2000-132-3-106


Source Citation

Grunfeld E, Fitzpatrick R, Mant D, et al. Comparison of breast cancer patient satisfaction with follow-up in primary care versus specialist care: results from a randomized controlled trial. Br J Gen Pract. 1999 Sep;49:705-10. [PubMed ID: 10756611]


Abstract

Question

In women with breast cancer in remission, does the level of satisfaction with health service delivery differ when follow-up is done in a primary care setting rather than in a specialist-care hospital outpatient setting?

Design

Randomized {allocation concealed*†}, unblinded,* controlled trial with 18-month follow-up.

Setting

2 district general hospitals in England, U.K.

Patients

296 women (mean age 61 y) who had breast cancer in remission and were receiving follow-up care at 1 of 2 general hospitals. 266 women (90%) and 256 women (86%) completed questionnaires at the middle and end of the trial, respectively.

Intervention

Women were allocated to follow-up care by their own general practitioner (GP) (n = 148) or to usual follow-up care from 1 of the 2 hospital outpatient clinics (n = 148).

Main outcome measures

Patient satisfaction was measured using a questionnaire developed by the U.K. College of Health. For analysis, the statements were grouped into 3 categories: those relating to service delivery, consultation, and continuity of care. Choices for response were “agree,” “agree sometimes,” “disagree,” and “can’t say.” The first 2 were grouped together in the analysis.

Main results

Mid-trial results were reported because they were completed within 10 days of a follow-up visit and did not differ from end-of-trial results. Analysis was by intention to treat. At mid-trial, women who received follow-up care from their GP indicated greater satisfaction than did women who received routine follow-up care in an outpatient clinic; statistically significant differences were seen between groups for responses to 9 of 12 statements (P ≤ 0.009). For all but 2 statements about the consultation, more GP-group patients indicated improved satisfaction at mid-trial over that at baseline than did patients in the outpatient-clinic group. Hospital outpatients showed greater satisfaction from baseline with only 1 statement about service delivery.

Conclusion

Women with breast cancer in remission had a higher level of satisfaction with health service delivery when follow-up was done by their general practitioner than when it was done in a specialist-care hospital setting.

*See Glossary.

†Information from BMJ. 1996;313:665-9.

Sources of funding: Department of Health for England and Wales; Ballakermean School of the Isle of Man; Imperial Cancer Research Fund.

For correspondence: Dr. E. Grunfeld, Ottawa Regional Cancer Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada. FAX 613-725-6308.


Commentary

The observation that patients with breast cancer in remission are more satisfied with follow-up in a general practice setting than in a hospital specialist clinic is intriguing. However, as Grunfeld and colleagues recognize, satisfaction with care is an important outcome measure, particularly when it has been shown that medical outcomes are not affected. Although a previous report of this study suggests that this lack of clinical effect is the case (1), too few events for which early treatment is important (particularly local recurrences after lumpectomy) occurred to be confident that differences did not exist. Pending confirmation, the current report suggests an approach to follow-up that can be considered in the future. For women who are willing to consider follow-up in a general practice setting (one third were not) and for GPs who are willing to accept this responsibility (in an Ontario survey 10% were reportedly unwilling [2]), general practice is a possible option. However, whether sufficient unused general practice resources exist to meet this demand has not been addressed. Patients who have strong preferences for follow-up in specialist settings, and for whom follow-up in such settings would be most appropriate (e.g., those with treatment-related complications), will continue to exist. Furthermore, patient preferences and satisfaction with care may differ considerably in health care systems other than those of the British National Health Service. Additional research with longer follow-up is needed to understand the effect of follow-up on medical outcomes and to ensure that satisfaction with care in general practice, measured early after transfer of care to that setting, did not reflect response to a “new situation” and that it continues with prolonged follow-up. Another study by Grunfeld and colleagues is currently being done, and results that may clarify some of these issues are expected in about 2 years (3). Satisfaction measured by other groups and in the health care systems of other countries should also be evaluated.

Pamela J. Goodwin, MD, MSc
The Mount Sinai Hospital
Toronto, Ontario, Canada


References

1. Grunfeld E, Mant D, Yudkin P, et al. Routine follow up of breast cancer in primary care: randomised trial. BMJ. 1996;313:665-9.

2. Worster A, Bass MJ, Wood ML. Willingness to follow breast cancer. Survey of family physicians. Can Fam Physician. 1996;42:263-8.

3. Grunfeld E, Levine M, Coyle D, et al. A status report on a randomized trial of follow-up strategies for breast cancer. Canadian Breast Cancer Research Initiative: Reasons for hope. Toronto, June 1999.