A Patient-Centred, Evidence-Based and Multidisciplinary Approach to Care
A cancer diagnosis often brings about fear, anxiety and sometimes depression for patients, carers and their families. Cancer itself is a threatening experience and the acquisition of more information by those affected is associated with higher levels of satisfaction, compliance and psychological adjustment21,22. Patients undergoing radiotherapy have multiple fears, anxieties, stress and expectations23,24. This anxiety and depression adds costs to other Government services such as psychiatry and psychology services, other support services and in General Practice. Accessing these services is a particular problem in the rural setting where many are not readily available.
Radiation oncologists and other staff (such as radiation therapists, medical physicists and nurses) are actively involved in providing information to patients, particularly in the early stages of the treatment process25. There are no standard guidelines for the timing of information provision, and individual departments vary in terms of the level of information that they provide and the setting in which the information is provided. Increasingly, cancer patients and the broader community seek to be active participants in health-care decision-making26. The development and availability of evidence based information for consumers and the community supports informed decision-making and enables individuals to act to improve their health outcomes.
Consumer representatives on the Tripartite Committee have recommended that the following principles should be in place with regards to informing consumers:
All patients and their families should have up-to-date, evidence-based and relevant information regarding radiotherapy;
The information needs to be accessible to all. Information should be available, via interpreter services to patients and their families where their primary language is not English;
The option of radiotherapy should be offered when it is clinically appropriate;
The advantages and disadvantages of radiotherapy and treatment alternatives should always be discussed, including the information on the potential short and long term side effects;
Costs (including gap payments) associated with radiotherapy in private radiotherapy centres should be made clear because the financial strain can add to the pre-existing stress and anxiety. This information should include whether the fees are to be paid up front or whether only the gap between the Medicare rebate and the actual fees is to be paid.
Currently, specific patient information about radiation oncology is not consistent or comprehensive and in many cases seen as too technical. In Australia there is lack of centrally-located, clinically-appropriate, credible and easily accessible information for patients, carers and families on procedures and treatments in the area of radiation oncology. The benefits of an easily accessible radiation oncology patient information resource could include:
A national source of reliable and credible information about radiation oncology
Easier access to this information by cancer patients and practitioners living in rural or remote locations, where access to reliable information is limited, thereby providing equitable access nationally to all Australians wherever they live
Increased transparency of clinical decisions improving the likelihood of the improved evidence based treatment techniques, technology and systems being used consistently across the nation
Contributing to informed patient consent and practice risk management
Providing access to this information to professionals involved in providing radiation oncology increasing the likelihood of consistent and appropriate advice being provided to patients, carers and their families
Reducing consumer anxiety about radiation oncology treatments caused largely by lack of understanding or fear of the unknown or inappropriate information
Decreasing patient uncertainty thereby possibly reducing costs to other Government services and support services such as psychology, counselling and psychiatric services
- Reducing costs to jurisdictions by eliminating the need for each jurisdiction to produce these resources on their own
Radiation oncology practice standards
The 2002 Baume Inquiry identified a number of national safety and quality issues relating to radiation oncology. Recommendation 26 was that ‘a facility accreditation program should be developed as a matter of priority … with input from 3 professions, it should be tested in 2004 with full accreditation starting in 2005 and made a condition of continued funding in 2006’. Recommendation 27 was that ’the accreditation program should initially cover national guidelines for minimum Quality Assurance (QA) processes and dosimetry program. New requirements should be introduced as they become practical’.
Radiation Oncology Practice Standards, a Tripartite Initiative, outline the components of a quality radiotherapy service at facility level. Facility management is considered to be of vital importance in the delivery of safe, quality care to radiation oncology patients. The standards encompass three domains:
Treatment Planning and Delivery
Safety and Quality Management
It is the Tripartite’s view that the Standards should be made mandatory and that this should be achieved through legislation. The legislation should mandate compliance and will refer to the Radiation Oncology Practice Standards but should not enumerate them, so as to allow regular reviews of the Standards in line with contemporary practice. If legislated, compliance with the Standards would become a function of normal business operations for each facility. The following two steps are important:
Incentivising facilities to reach the required Standards and providing resources
Ongoing facility participation should be mandated and incentivised through the Medicare Benefits Schedule
Evidence based multi-disciplinary oncology practice
Cancer patients can receive treatment from a number of medical professionals. This can create challenges in the delivery of consistent care and in the coordination of care between expert clinicians. Multidisciplinary management is designed to overcome this fragmentation and ensure that best practice is delivered enabling optimal patient outcomes to be achieved, contributing to improved survivorship outcomes14. There are additional benefits to multidisciplinary practice, including opportunities for patients to be identified as suitable for clinical trials and as forums for professional development, and quality improvement activities for the team27.
Cancer Australia is promoting the medical multidisciplinary team (MDT) approach nationally28 with state-based initiatives to monitor and encourage MDT practice already in existence. The work of the NSW Cancer Institute is one such example. MDT practice is a critical component of quality care and should be embedded and strongly encouraged in service planning and delivery.
The MDT would consist of radiation oncologists, surgeons, medical oncologists, and haematologists. It is acknowledged that a range of other clinical health professionals make important contributions to the treatment decision-making process, these professionals may include nurses, pharmacists, radiation therapists, medical physicists, nuclear medicine physicians and radiologists amongst others. This collaborative approach allows the MDT to make decisions about the most appropriate treatment and supportive care for a patient, while taking into account the individual patient’s preferences and circumstances including their care and family arrangements29.
Once the decision to utilise radiotherapy for treatment has been agreed, a radiotherapy specific MDT consisting of radiation oncologists, radiation therapists, and medical physicists, as well as other professionals as required from time to time, should discuss and review the technical details of the treatment planning and delivery.
Clinical peer-review audit
It is argued that ’high-quality’ means minimising process variation and moving the average closer to the optimum value. In radiation oncology this should mean a consistent and up-to-date set of specifications for treatments and procedures30.
Peer review is a quality tool that is used to enable practice-based improvements in clinical practice and patient care. ‘Review by Peers’31, a document prepared by the Australian Commission on Safety and Quality in Healthcare (ACSQHC), states that “review of professional practice by a peer is a valuable and important part of the maintenance and enhancement of a health practitioner’s clinical and professional skills”. The importance of participation in peer review activities by health practitioners has been identified by the Medical Board of Australia in the Continuing Professional Development Registration Standard32, highlighting that CPD (now mandatory as a condition of registration) must include practice-based reflective activities such as peer review.
The Faculty of Radiation Oncology, RANZCR, strongly supports the participation of radiation oncologists in peer review activities and has developed a Peer Review Audit Instrument33 to help ensure an effective peer review process. The use of this tool by radiation oncologists is strongly encouraged before radiotherapy treatment has commenced and ideally after all planning has been completed to ensure its results are the most beneficial for radiation oncology practice. This way, patient care and treatment are optimised. The Peer Review Audit Instrument is also used for radiation oncologists returning to practice from an extended break in clinical practice34. The importance of peer review has been embraced in radiation oncology and mandatory participation in practice-based reflective activities such as peer review audit, clinical audit and attendance at multidisciplinary team meetings has been introduced35.