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On Referral Patterns for Patients With Breast Cancer

RAND, Santa Monica; and the David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA

In this issue of the Journal of Clinical Oncology, Katz et al¹ describe mechanisms by which newly diagnosed breast cancer patients report selecting their surgeons in two large cities. They found that 54% of women reported that they were referred to their surgeon by a clinician or health plan, 22% reported they self-selected a surgeon despite having been referred by their clinician or health plan, and 20% self-selected their surgeons without a referral. Patients who selected their own surgeons were more likely to be treated by high volume providers in an American College of Surgeon–approved cancer program or National Cancer Institute–designated cancer center. The authors raise concerns for women who are directed by clinician referrals and health plans to surgeons with lower volume and not necessarily associated with cancer programs.

Their concern rests on the increasing evidence of lower mortality in association with high volume institutions and high volume surgeons across multiple clinical conditions, including cancer. Luft^2,3 developed the practice makes perfect hypothesis as a model to explain how higher volume might improve outcomes. High volume allows more training, development of stronger skills, and more experience. In addition, high volume institutions and providers gain production efficiencies, allowing for economies of scale and savings when purchasing costly equipment and specialized services. Improved survival and efficiencies in operations motivate more referrals, resulting in even more patient volume.

Over time, substantial evidence supporting lower mortality rates for patients receiving complex medical care and high-risk surgical procedures in institutions managing high volumes of patients have been noted across multiple studies, countries, clinical conditions, procedures, and settings.^4,5 Birkmeyer et al⁶ and colleagues have shown consistently higher mortality rates in lower-volume hospitals for six cardiovascular and eight cancer surgical procedures. Begg and colleagues⁷ showed postoperative deaths and morbidities were higher after radical prostatectomy for patients associated with lower volume hospitals and surgeons. Both studies showed the magnitude of the effect varied by surgical procedure, even after adjustment for case mix.

Both studies, as well as a myriad of others across countries, clinical conditions, and settings have found similar results for high-risk surgical procedures.^8,9,10 Hynes and colleagues¹¹ found that higher-volume hospitals treating breast cancer had lower postoperative lengths of stay and readmission rates, which are both indicators of lower costs and better quality. Hillner et al¹² found the association between outcomes and provider volume was much stronger for cancers requiring high-risk procedures, such as pancreatic, esophageal, and gastric cancers, and hepatic resection, than lower-risk procedures, including breast cancer.

With these data in mind, policy makers across the years have struggled to define actions to respond to the accumulating evidence that higher volume predicts lower mortality.^4,5 How and for which conditions should actions be implemented? Some, like the Leapfrog Group, a coalition of key stakeholders, have advocated selective referral in urban centers for high-risk procedures.¹³ But, as Epstein⁴ has described, many unresolved issues remain. Is there an exact cut point to define high enough volume? How stringent should adherence be? What kinds of data are needed to set that threshold? Should insurers, providers, or patients decide circumstances when that threshold should be overridden? The data presented by Katz et al¹ show that women who self-selected their surgeons, as compared with being directed by their clinicians or health plan, were significantly more likely to be white, highly educated, affluent, and were more likely to have had second opinions. They report that self-selection of surgeons was not associated with patient age, tumor characteristics, or geographic site.

For the clinical area described by Katz and colleagues,¹ we need to ask how, if at all, the data supporting a volume-outcome link for breast cancer, a condition not considered as high-risk in terms of short-term mortality as other procedures, should influence referral patterns for breast cancer patients. Optimal outcomes for breast cancer patients require more than good initial surgical interventions. Multiple interventions across disciplines and time are needed. As demonstrated in the recent American Society of Clinical Oncology–funded National Initiative for Cancer Care Quality (NICCQ), multiple domains of quality contribute to assuring that patients receive the care needed to optimize their outcomes.¹⁴ Patients need access to high-quality pathology services, as well as adjuvant treatment with chemotherapy, radiation, and hormonal therapies as a supplement to initial surgical procedures.¹⁵ Furthermore, coordination and continuity of care are needed to assure symptoms are managed, comorbid conditions are addressed, and treatments are continued.¹⁶ To date, little is known about how volume influences these domains of process.

The Institute of Medicine has described six aims considered essential for the redesign of health care: care should be safe, effective, patient-centered, timely, efficient, and equitable.¹⁷ While they might have focused on structural characteristics to improve quality, they selected more specific targets such as processes more proximate to patients and their outcomes. Recommendations for the development of specific performance measures and the evaluation of specific clinical outcomes have also been recommended.¹⁸ Recent efforts of the Centers for Medicare and Medicaid Services, National Committee for Quality Assurance (NCQA), multiple specialty organizations, and the Institute of Medicine have not been to reorganize the delivery of most components of health care with volume as the solitary end point. Instead, the focus has been on the reorganization of services to assure patient-centered care, continuity, and coordination of care, based on implementation of evidence-based care.¹⁹

While volume is known to link to higher survival rates for high-risk surgical procedures, the influence of volume on multiple domains of processes and outcomes for breast cancer patients is less clear. We do not know whether organizing the care of breast cancer patients around institutional or surgeon volume would increase or decrease breast cancer care overall. Would it increase the likelihood for appropriate use of hormone replacement? Would it increase the likelihood that women who initiate hormone replacement remain on the treatment for the full benefit achieved only after continuous treatment for multiple years? Would it assure referral to a radiation oncologist when needed, or avoid underuse of supraclavicular boosts for high-risk cancers or to protect nearby organs from excessive radiation?

Breast cancer requires care from multiple providers, which is true for most chronic conditions. Each provider participating in a patient's care has the opportunity and the responsibility to deliver optimal care themselves, but each also carries the responsibility to assure a well coordinated sign-off to other providers who will contribute to the patients' outcomes. It is not known whether patients who select their own providers will fare better in processes and outcomes than those who follow the recommendations of their providers and health systems regarding a particular surgeon. While for some conditions, the surgical intervention is the sole predictor of outcomes, for other conditions—involving multiple treatments—we do not know the best strategies for predicting consistent high quality care across treatments and time.

Katz and colleagues¹ have performed a valuable service by identification of the importance of structure, which they define in terms of the individual providers linked to patients and the volume associated with those providers. Today, we are in a rapidly changing era with many metrics for assessing structure beyond volume alone, and for many metrics assessing processes and outcomes that reach beyond the structural characteristic of volume.^17-19 We are in the midst of an intensive evaluation of measures for assessing the quality of cancer care that now, for the first time, addresses patients' needs across domains. Screening, diagnosis, staging, decision making, initial treatment, adjuvant care, and follow-up care are all important to patients. Strategies to define these for most patients, and for those with particular needs such as advanced age, comorbidity, and socioeconomic constraints, are all under consideration. While it would be naïve to think an ongoing quality measurement system is fully ready, multiple forces are clearly converging in that direction. Thus, we should think carefully before adopting a practice of referrals based only on volume metrics. Other characteristics to consider in optimizing referrals should include patient comorbidity, severity, and preferences, as well as existing relationships between the patient and providers. Practical considerations are pertinent for some patients including access considerations such as transportation and language concordance. In some instances clinical considerations will be most important, while in other instances consideration of patients' values and practical needs will be paramount. With continuity and coordination of care being recognized as important aspects of quality, the abilities of a consultant to provide continuous and coordinated care should also be considered for each patient. Finally, clinicians working with clinicians often learn important insights about their colleagues that facilitate effective matchmaking between patients and consultants. Allowing clinicians to supplement volume considerations with those pertinent to their patient's unique needs, as well as prior experiences with colleagues, affords a valuable option that should be preserved, even if it sometimes overrides volume considerations.

Several studies are forthcoming to help us understand these issues further. American College of Surgeons studies using National Cancer Data Base data, Rapid Case Ascertainment studies, and Surveillance, Epidemiology and End Results–Medicare studies will continue to reveal where patients receive care and what happens to them. For years, the National Comprehensive Cancer Network (NCCN) has been generating guidelines about how clinical care should be delivered, based on the best available evidence.¹⁵ Last year, the American Society of Clinical Oncology–funded NICCQ published the first national report of clinically detailed quality of care measures in the United States.¹⁴ The Los Angeles Women's Study of incident breast cancer patients and their providers will soon address a taxonomy describing the underpinnings of referral patterns described by physicians caring for breast cancer patients. ²⁰ Soon to follow, National Cancer Institute–funded Cancer Care Outcomes Research & Surveillance Consortium (CancORS) will report population-based analyses describing care and outcomes for patients with two prevalent cancers.²¹ Evidence is accumulating to help us understand how processes should be delivered to optimize patient outcomes.

For now, encouraging physicians to practice evidence-based medicine, encouraging patients to become informed about their diseases, and encouraging the conduct of ongoing studies of health care delivery in community settings as a supplement to those in academic settings is likely to move us toward providing better care. The delivery of health care services rests on the shoulders of physicians. For breast cancer, evidence does not currently support improved patient outcomes from replacing physician judgment and expertise with strict volume criteria as a strategy for identifying surgical referrals.

AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author indicated no potential conflicts of interest.

ACKNOWLEDGMENTS

Supported by National Cancer Institute Grant No. AHRQ 1-R01-CA81338-01A1.

REFERENCES

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