A “group visit” model, led by nurse practitioners, is a feasible and highly satisfactory means of following breast cancer survivors, according to 2 oncology nurse researchers from the Duke Cancer Center’s program.
Kathy J. Trotter, DNP, CNM, FNP-C, and Susan M. Schneider, PhD, RN, AOCN, FAAN, described their breast cancer survivorship clinic at the American Society of Clinical Oncology 2012 Breast Cancer Symposium held in San Francisco, California, in September.1
“The group visit replaces the follow-up medical appointment. The idea was to offload the medical oncologists so they could see more newly diagnosed and sicker patients,” said Trotter. “This is a billable service that I as a nurse practitioner provide, though oncologists could do this as well.”
“We love it, the patients like it, it works,” she said.
Follow-up Clinic Begins 3 Years Postdiagnosis
The group medical appointment for breast cancer survivors was initiated at Duke Cancer Center in 2008, adapted from the Centering Healthcare Institute model. Patients who are at least 3 years postdiagnosis attend the clinic together in groups of 6 or 7.
An interdisciplinary group visit format in the front-end of the appointment provides education and support. The first hour includes a review of the patients’ personal care plans and a 45-minute facilitated group discussion. After this, half the patients leave for mammography and laboratory testing, while half remain with the nurse practitioner and have access as well to a dietitian, social worker, or physical therapist.
“It is important to make this visit multidisciplinary,” she said. “They are most interested, at this point, in talking with a dietitian,” she added.
Very Satisfied Patients
The researchers evaluated the level of patient satisfaction with the model and also determined if there might be a cost benefit to the group visit model.
A 22-item Likert-type questionnaire sought opinions from 122 patients regarding logistics and the style and function of care delivered. Second, a retrospective analysis of clinical fi-nancial data on 300 patients was performed. For this, revenues from the group medical visit by the nurse practitioner were compared with those obtained from traditional physician visits. A review of time to the third available appointment for each clinician was also recorded.
Overall, 98% of the 122 respondents felt the program provided quality care, and 97% were likely to recommend the clinic to other breast cancer survivors. More than 80% of respondents added comments, with the vast majority being positive. From these comments, several qualitative themes emerged, most strikingly that patients appreciated the opportunity to share with other survivors and to receive nursing care with such a high level of attention and professionalism.
“At first I was wary about this program, but only one visit converted me,” one patient wrote. “It felt warm and friendly, versus clinical, which is exactly what I needed.”
Program Is Cost-Effective
The cost-benefit analysis revealed that revenues and direct costs were nearly equal between the 2 delivery models. A review of time to the third available appointment for the primary referring oncologist dropped from 29.4 days to 26.7 days, while the nurse practitioner’s time remained stable at 8.7 days.
“Our financial manager told me that for each new patient that the oncologist is free to see, that is $8400 [revenue] for our budget,” Trotter said.
But what is immeasurable is the community value of a center that takes care of its patients. Even though we are not actually making money from this, patients are spreading the word that we are a center that will take care of you.”
William Sikov, MD, of University Medicine in Providence, Rhode Island, led a “poster discussion walk” at the meeting, where he commented on the potential value of this format. He said the patient volume at large medical centers “threatens to swamp the ability of physicians to see patients for follow-up, to the detriment of seeing new patients. This is an interesting approach.”
Sikov suggested one of the greatest benefits is the group sharing experience in which patients feel the commonality of their condition. “I may have a difficult time convincing the stage I patient with a twinge in her knee that she doesn’t need a bone scan. It is meaningful for patients to hear from around the room that other patients have these symptoms too. They see that certain things really are common.”
Trotter responded that such peer support is part of what the group visit offers. “But my job is to see that we get the correct information out,” she said, “and that patients understand when they don’t need to worry, and when they need to see us right away.”
- Trotter KJ, Schneider SM. Evaluation of a breast cancer survivorship clinic that uses a group medical appointment model: patient program evaluation and financial analysis. Presented at: American Society of Clinical Oncology 2012 Breast Cancer Symposium; September 13-15, 2012; San Francisco, CA. Abstract 90.