Contemporary treatment of primary cancer may involve surgical resection, single- or multiple-agent chemotherapy, radiation, hormonal, or targeted biologic therapy. Secondary management may include treatment of or assistance with nausea/emesis, pain, anemia, depression, disability, impaired communication, and other issues. The complexity of this process means that it will be filled with transitions. Patients will receive care from multiple providers, in multiple locations. Active treatment will give way to follow-up care, which in turn will yield to extended “survivorship” management. If improperly handled, each of these hand-offs can be problematic, confusing or worrying the patient and compromising the ability of providers to deliver optimal care. Managing these transitions can be diffi cult, requiring as it does that an enormous amount of information about each patient and his or her disease be shared quickly and accurately among many providers. If only there were a tool, let’s say a vast network of computers on which this data could be stored and accessed from multiple points of entry, to ease the process...Continuity begins with a definition
There are hundreds of definitions of “continuity of care,” but we like the one proposed by Haggerty
, et al. best: “for patients and families the experience of continuity is the perception that providers know what has happened before, that different providers agree on a management plan, and that a provider who knows them will care for them in the future.” Haggerty and colleagues suggested three types of continuity; in the same year, John Saultz
, MD, introduced two more (see Table). The experience of a patient with cancer may be divided into two phases: the period of time during which active treatment is provided, and the “survivorship” period, during which therapy has been completed and/or cancer is controlled, but follow-up care continues. Th ese phases are not always distinct, may overlap, and may even alternate. Eff orts at ensuring any of the types of continuity described above must take into account both phases.In-treatment continuity
Continuity of care is important during active treatment. A cancer diagnosis is confusing and frightening, and the treatments administered may produce adverse reactions that exacerbate symptoms related to progression of disease. Lack of continuity may make patients feel insecure—“my doctors can’t agree on how to help me; maybe none of them know what they’re doing”—and less likely to adhere to their treatment plans. It also introduces any number of other potential problems. To understand how, consider the standard treatment workfl ow for a patient with cancer. A patient will arrive on the day of treatment and undergo testing and physical examination. During this time, the oncologist will conduct an assessment of any adverse events encountered since the last session. Th e oncologist will then issue an order for the treatment agent(s). The patient will then move to a treatment room, where a nurse administers therapy prepared by a pharmacist and documents treatment to be reviewed by the oncologist at a later date. Th e patient is discharged. Before the next session, the patient may visit his or her primary care physician (PCP) and/or the hospital for emergent complaints.
Now, consider the opportunities for error inherent in this system, if information and management planning do not combine to make a continuous care experience. The oncologist may make prescribing errors or be unaware of drug–drug interactions (especially if the patient was prescribed a new drug by his/her PCP and forgets to inform the oncologist). Chemotherapy-related toxicity that occurs and is managed between treatment sessions may not be reported to the oncologist. The nurse administering therapy may not have access to important patient-specifi c notes that aff ect the administration.
These issues come into even more stark relief during times of emergency. Hurricane Katrina displaced thousands of people, many of whom were cancer patients receiving active treatment. Some patients presented to hospitals with only the most basic information about their cancer—“I get chemo for breast cancer, but I don’t remember the name. Stage? I can’t remember.”—and limited information on allergies, treatment history, and the like.Survivor continuity