'Beyond Bricks and Mortar - Building Quality Clinical Cancer Services' Symposium 2011

Novel Ways to Enhance Rural Patients Access to Cancer Services - Dr Sean Brennan

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Senior Radiation Oncologist, Townsville Cancer Centre, Queensland Health

Download powerpoint presentation by Dr Sean Brennan (PDF 4398 KB)

Norman Swan:

So you know, you’ve got your radiation oncology service, how do you enhance access to it? Sean Brennan’s going to talk to us about that, he’s a Senior Radiation Oncologist at Townsville, Director of Training there, he’s got an appointment at James Cook University and he has a long interest in rural based support for people with cancer, and hailing from rural Zimbabwe. Please welcome Sean.

Dr Sean Brennan:

Ladies and gentlemen, thank you very much indeed for the opportunity to address you this morning on essentially what are novel ways of enhancing access of cancer patients to care. Now this technology is a quantum step from the technology that Tomas has been discussing, very, very, very much more simple, and to be perfectly honest we’ve got (unclear word) gratifyingly in this particular occasion if the patient is 10 centimetres to the left, it really doesn’t matter at all. The quality outcome will be the same.

What do we know? What do we know about rural populations? Well we know that the care of rural populations in sort of diffuse rural areas, is actually one that is common to a number of continents, it’s not just unique to Australia, it’s common to South Africa, to the United States to Canada. So there is a lot of data coming out of these countries, where clinicians are trying to optimise access for these patients. We have low health worker numbers relative to the size of the geographies that have to be covered, and we have long distances in which the patients have to travel. These are intuitive, and these are factors that we know.

There are a number of models of care which exist and indeed a number of them exist here in Australia. Oncologists travel to rural centres alright, consultations and follow-up take place at those rural centres, but nonetheless the patients still have to travel to a regional centre for treatment. The alternative is that oncologists travel to a rural centre, consultation and follow-up is done there, limited treatments are available there. I’m practicing as a radiation oncologist here, but I speak on behalf of my colleague who is a medical oncologist, Dr Sabe Sabesan, in fact who is really in the Townsville region and pioneered a lot of this work. And so what the medical oncologists and the haematologists are able to achieve under certain circumstances, is the provision of a number of limited treatments relatively easy, relatively safely administered, relatively non-toxic intravenous chemotherapies that can be given in a relatively short period of time whilst the clinician is in their visit. And then of course there’s the model where simply everything happens at a regional centre and all patients travel.

Well telelink gives one an alternative model to this, I’m not saying this is the solution, I’m saying that this is yet another card in the pack that we can look at. And in fact there are a couple of advantages to the telelink model, it’s very patient centred alright; the care goes to where the patient is, it has the opportunity for an MDT-like interaction in that increasingly we see a great willingness of the specialists in the rural centres to want to be involved in the very first consultation with the patient, almost invariably the primary health care physician is involved in the consultation, wants to be a part of it. It gives access to a number of the allied health members. So we really have a far more rounded access to the patient right at the first hit with the patient, if you want to look at it like that.

Now I’m from Townsville. Where’s Townsville? Northern Queensland. You know that. It’s a tertiary referral centre in the north of Queensland, depending on where one draws the boundaries for referral, with a population base of about 650,000 people. Now the medical oncology models are really the models that have been very well established in telelink in Australia, in the Townsville area. In fact they’ve evolved from that first model of patients having chemotherapy delivered while their doctor was at a rural centre to the doctors staying in the regional centre dialling in right, and creating an infrastructure. And the best example we have this is the Mount Isa model, where there is an infrastructure that has been created now where in fact the provision of chemotherapy, virtually all forms of chemotherapy is undertaken in Mount Isa.

The patients are seen via telelink from Townsville, there are responsible clinicians present in Mount Isa with the patient, the necessary ancillary staff for the administration of chemotherapy is present, the patient is present, and the patients in many circumstances never leave Mount Isa for the duration of their treatment. Now that is easier to achieve in medical oncology. It's not easy to achieve in radiation oncology, clearly because we are dependent on regional centre technology right? Similar to what you will understand from what Tomas was saying, this is not available at every rural centre.

So we looked at seeing how could we piggyback on the basis of some very sound work done by our medical oncology colleagues, and we’re looking at the opportunity to say right, if we've got rural based patients, can we access that patient in the first instance, via a telelink? Certainly we can.

If we need a subsequent consultation, I’m thinking perhaps of a head and neck patient who requires a PET scan or an MRI for further evaluation, rather than that patient coming down for that first consultation and going back home again, and going down to Brisbane to have a PET scan, and going back home again and coming back down for a consultation. All of that can be very uniquely coordinated by a distance management, and those can be coordinated, they can be collated, they can be discussed with the patient. So the patient makes a fully informed decision on what his treatment options are before they come down for perhaps exposure to a multidisciplinary clinic in a head and neck environment. Or in the case of breast carcinoma or prostate carcinoma, before those patients come down for a planning session. Planning, treatment delivery has to take place in the regional centre alright? That’s the situation that we have at the moment’s time, but then thereafter that patient can return home and very satisfactory supervision of their follow-up can be undertaken without unnecessary travel.

Sabesan, Varma, Nel, a number of names that are familiar to those of you who have been involved in telecare in Australia, have looked at what are the advantages that we see here. Certainly patient consideration, patient convenience, the patients have identified - the patients themselves from work done by Sabesan, have identified a number of factors why they like it. It’s cost saving for them. This is quite independent to the cost saving to the state, it’s cost saving for the patient for out of pocket expenses. It's time saving for the patient, it’s travel saving for the patient, and it minimises disruption to family time. A lot of these patients are travelling two days to get to a consultation that’ll last 15 minutes and travel a day or two home again.

So a lot of this - these are factors that the patients identified, this is why they’d like telelinking, alright? We like telelinking because it obviously affords that opportunity for the patient, but we also get an excellent interaction with the primary care physician, right up front. Face to face, you establish an excellent relationship with that clinician right at the very outset. And of course for in the north of Queensland when the wet season comes in, large quantities of the state maybe inaccessible, the Gulf of Carpentaria area for example, is simply impassable for about four months of the year.

Urgent medical care is something that can also be provided via this. Now this is more applicable to medical oncology and haematology, again and requires very close liaison with the clinician who’s present in a rural centre, but Sabesan and Nel have demonstrated an 80% reduction in the referral rates for patients requiring emergency intervention, simply because that intervention can be undertaken via supervision at the distant hospital. Not so for radiation oncology. Urgent intervention in the form of radiation will still require that the patient come in, but we do have the opportunity for stabilisation, that patient just has a little more finesse to be able to deal with the clinician face to face.

One of the things that was really interesting that came out of this was looking at accommodating Indigenous cultural needs. Now again looking at some of our data when we looked at the consultations that were undertaken with Indigenous patients and Aboriginal patients and Torres Strait Islander patients, we saw that we had in fact an average of about four family members come with the patient to be involved in this consultation. The sense of community, the sense of family involvement in decision making, it’s not a sort of patient centred decision making, but a family community centred making. We have up to four family members involved. And increasingly we’re seeing some of the local involvement of the local traditional healer, not that traditional healers are at variance with what we’re wanting to be recommended from our perspective, but that there’s this mounting interest that we have an opportunity to work hand in hand in this environment.

And the other thing that arose out of this which was rather fortuitous, was this ad hoc opportunity for education, particularly with some of the larger family groups that arise, there was almost invariably the question sort of saying, "So this cancer is smoking-related you say?", :Yes". There’s an opportunity, alright? So we were able to give a little bit of ad hoc information about cancer prevention and cancer risks associated with certain environmental and lifestyle activities.

I mentioned to you the distances that are involved, these are just six of some of the centres that are six of the busiest centres that we do in a telelink environment, which arrange - I mean Badu Island is a very long way away, it’s just south of Papua New Guinea. So for patients to travel from that environment it’s really quite taxing. Gulf of Carpentaria, 1200 kilometres. So these are big distances that we can avoid for the patient. But that’s not to say that it’s not without challenges, there are challenges associated with this, but fortunately because of the level of technology, these challenges are actually really easy to overcome. The technology is there, the technology is widespread, there are video linking facilities available in the rural centres, they work well, they’re very simple.

And I mean not to be patronising when I say this, but they are that simple that often a patient who is not with a healthcare worker who has been trained of the outset of the consultation, can quite easily adjust the volume or do something very simple to the monitor that’s in front of them, and now that’s not to be patronising. That’s rather to say that this is important that the level of intervention here is something that can be accessible and not completely off-putting to the patient alright. It’s very well supported, there is a network that supports the use of tele-oncology, the use of tele-networking alright. And there are training facilities offered, very often you find in these rural centres there is a nurse or there is a general practitioner who becomes particularly interested in this. They’re welcome down to Townsville, they have access to all sorts of online telephonic support to be able to say exactly how this should work.
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We were a little bit concerned at first and about, what about visually and hearing impaired patients? Well we have a small cohort of 38 patients, the first 38 patients that we did in radiation oncology, where we just asked the patients to self assess whether they felt in normal social circumstances that they were either visually or auditorily impaired to the extent that it made some impact but didn’t deter them from normal interactions. And in fact just under 50% of them volunteered that they were, that they noticed, you know, ‘cause people had to speak up a little bit, or they had to get a little bit closer to a book to read it or something like that, simple things. Not one of those patients found that the telelink opportunity afforded them any challenge, simple things, zooming on the screen, volume determination was easily overcome.

Now if we look at what experience do we have in Townsville? Well we’re slowly amassing some patients with which we’re getting this experience. If we look at the numbers from the Medical Oncology Department, which have now been running this for four years, in a more accelerated setting in the last two years. And the radiation oncology really for about the last 18 months, we have a sizeable number of follow-ups, and we really have a significant number there of just under 800 contacts with patients via a telelink on which we can base our assessment of them.

In terms of the diagnoses, this represents a little bit of, let’s say initiation by us, in the sense that in Townsville what we have is we have a lot of the specialists have sub specialities; it hasn’t been embraced by all specialists yet, and so what you’ll see here really is a bias in terms of the sub speciality of the clinicians who have embraced the telelink. So it’s not to say that I believe that this is what it is limited to, not at all, but this just represents the patient profile that we have at this moment in time. The bulk of the patients are prosthetic carcinoma patients, some lower GIT, skin and lung patients, with lymphoma and breast making up a sizeable quotient, and a small number of thyroid patients.

What we’ve done however as we’ve audited this, we’ve implemented this, but we’ve audited this from two points of view, to have a look and see does it work for us as the radiation oncologists and the medical oncologists, does it work for the patient specifically and does it work for the distal if you want to put it that way, the distal clinician? Well in our own radiation oncology say about the first 28 patients were assessed, the medical oncology have assessed their first 50 patients in a similar fashion. It’s questionnaire based. The questionnaire was based on a questionnaire that was developed in the United States and in Canada. So we have some broad means of comparing our data together. It’s ethics approved, it’s consent approved by the patient, it’s given to the patient or posted to the patient, with a request for the patient to post back. It's anonymous from the point of view that the patient doesn’t put their name on it. We do call our patients irrespective a few, about 10 days after the consultation and say, have you received this telelink form? Have you please returned it? If have they returned it, yes, if they haven’t returned it, another call to say please do return it, and basically it seeks some basic demographics.

And then there’s a series of satisfaction statements that we asked the patients to rate. And these are the satisfaction statements. It's scored from a one to five, one being wholly unsatisfactory, five being highly satisfactory to the patient. And we were looking at various things, we were looking to see does the patient feel that their privacy and confidentiality was assured or was respected under these circumstances, and overwhelmingly those new patients felt that they were, yes. All of the statements were four and five with the bulk of them being five. We wanted to make sure that the patients felt that this was an interactive procedure. Could they access the position on the other end of the screen, and ask questions? Did they feel intimidated, were they able, did they feel free to ask questions? Again they overwhelmingly agreed that they could. They could see clarification that they could ask questions quite easily.

The important thing of establishing rapport, is it necessary, is it absolutely necessary in the patients’ eyes to have a face to face consultation to be able to establish a rapport, or could you do so via a telelink? Well it turned out from the patients’ perspective, they felt that we could. It was easy to establish rapport and explanation of the diagnosis and treatment options were very easy. We have a setup where we have two screens on the computer, we can toggle between a view of ourselves and one of the screens can be projected onto the patient's screen, we can outline - so we can demonstrate CT scans etcetera, blood results, we can use an interactive whiteboard type of approach as well. So there is no reason why an extremely thorough discussion cannot occur with the patient.

We have almost invariably a clinician or a nurse on the other side, and interestingly enough the patients didn’t in fact feel that it was necessary. We like it. We like it as an opportunity for education for the clinician on the other side, we like it from a medicolegal point of view, because of accurate documentation and distal sight if you want me to put it that way. But the patients didn’t necessarily feel that it was ideal. No one found it unsatisfactory, there’s a free text box that accompanies this statement, and all of the patients said simply that they didn’t feel like it was necessary. Nobody minded, they just they felt that they could cope very well on their own.

With those statements that have previously been determined by Sabesan, and what was most important to the patient, cost, time etcetera? Well that gives you a fairly good representation of what the patients felt, they don’t like travelling, everything is important, everything is important, but really travel represented a significant deterrent - not deterrent but a sort of a significant frustration to the patient. And then of course the sort of the acid test so to speak, to say, as far as the patients are concerned "Would you like more telelinks? Would you like to dovetail this with a visit to the specialist, or would you in fact like to abandon the telelink thing altogether and come in and see your ...?" Well no-one wanted to abandon the telelink altogether. A significant number of patients in fact just wanted to telelink. And we found ourselves with the situation that it’s actually quite difficult now to persuade patients please to come back in, and particularly those patients who we would like for that clinical examination from a specialist perspective. But a lot of patients say "Yep, very happy to do that", but as long as telelink remains in integral part of their care.

As far as the clinicians are concerned, the audit basically on the clinicians was done by the medical oncologists. We didn’t repeat it. It’s the same pool of clinicians who are looking after the medical oncology patients in the rural centres as the radiation oncology patients. So we didn’t repeat it, but these are sort of the spread of clinicians, whether it’s physician rural-based general practitioner or nurse clinicians who are present on in that, to sort of give you an idea of who we solicited opinions from. And some interesting things came out.

One hundred percent of the clinicians supported the telelink, so we were very pleased by that. The concerns that were raised were operational: are we sure it’s going to work? The answer to that was yes. We have a 4% discontinuation rate of our consultations because of technological interference. Patient based concerns: were the patients going to be happy? We hopefully have addressed that with the patient audit. Patient based concerns from the point of view as there is some sort of degrees of accessibility for the patient, there’s still some travel involved but it is less of an impact on the patient. And from the medicolegal perspective: are we sound on the medicolegal perspective? Well there’s been a lot of debate with the legal advisors surrounding this, and the situation is very little different in fact to a face to face consultation. A record is made of the consultation by the clinician that was taking the consultation, a copy of that is filed with the patient to send to the distal site, a record is made of the distal site of the consultation that’s taking place. Any interventions are undertaken within the standard operating procedures agreed to. So there is no deviation from practice or policy other than the sort of the non co-location of the clinicians, of the clinician and patient. And additionally the vast majority of these consultations have taken place, undertaken by the specialist as well, not by the registrar or medical officer.

Interestingly enough the rural clinicians did not feel that a clinical examination by a specialist or the fact that the patient did not have a clinical examination by a specialist was an impediment to us. They themselves felt that given sufficient education, given sufficient support and given sort of pointers to the sort of things that we would want them to do, were very competent and very capable and very willing to provide that clinical support, and we wholly, you know, endorse that as well.

So really drawing to a close now, just a couple of final things that are very important to look at. We are very satisfied that this works for us, it works for us. We’re very enthusiastic about this. It’s certainly providing a great deal of support for patients. The factors aside, is it relevant? Is it relevant to your specific situation? In our situation because of the enormous distances it is - it has a huge relevance. You’ve got to decide on the model of care: is it going to be a telelink based consultation, is it telelink alternating with clinical consultations? Do you have an additional opportunity for example, with nurse care practitioners to develop a telephonic network. We have a system we've dovetailed with this. We have some patients who for their four week or six week post radiation checkup, symptomatic checkup, and those patients who have had a relatively simple course through their treatment; that in fact is undertaken by a nurse care practitioner, and highly successfully so. How best to integrate consultations, whether they’re done locally as well or exclusively remote? The role of telephonic consultations as I mentioned to you, and just how well the best can be done.

Service level agreements are obviously important. More important were the terms of the medical oncologists with the provision of oncology. I’m not personally connected with that at all. The medical legal concerns of accurate documentation, accurate, reliable, reproducible, well distributed appropriate documentation. The equipment is there, the technology is simple, the training and the technology is effortless. And one thing that is of importance though is I think communication skills are important. Everybody has different levels of communication skills, alright, and I think the last thing that you want - and the patients have commented on this as well - is a clinician who is sort of startled by their celebrity status projecting themselves over on the telelink consultation, and sort of stunned into dumbness under those circumstances. It doesn’t work. And there may be a role for a little bit of coaching and a little bit of mentoring under those circumstances for patients to be able to – for clinicians to project their personality yeah, into the room with the patient.

In conclusion I don’t think it’s the answer to absolutely everything, but I think it’s a very valuable complementary service to the rural patient care. It's fully applicable to specialist oncology services, and I think there’s a great opportunity for other specialities to embrace us as well. It has a very high level of patient acceptance which we’re pleased about, and a very high level of rural clinician acceptance. And with that I’ll end and if there are any questions I’d be very well willing to face them.
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Norman Swan:

Payment for the GP at the other end, does the new Medicare schedule allowed for that?

Dr Sean Brennan:

There’s an interesting new development in the Medicare schedule, I must be absolutely honest with you, I’m not completely au fait with the payment scheduling at this moment in time, but I know that this is something that’s in evolution at this moment in time, because of the expansion of telecare services. So as far as I am aware there is, but I say I’m not sure of what that is to be absolutely honest with you. Certainly there is now payment on the proximal end, if you want to put it there, and there is a payment which in fact is wanting to encourage the use of telecare.

Norman Swan:

Now one of the issues, my understanding is of this in cancer surveillance when you’re going to rural centres, is image acquisition and the quality of image acquisition. Have you had problems with that?

Dr Sean Brennan:

Yeah, yeah. That’s a very good point, yeah. I think image acquisition in terms of availability of the necessary specialist image if you want to talk about that - CT scans or MRI, it’s not always immediately available in the rural centre. However what we have found is that there are often very good larger centres, sort of intermediary distances between us and the rural centre who do have the CT or MR or something like that. So there are lesser journeys for the patients, we can’t accommodate all of those issues unfortunately.

Norman Swan:

And they’re good enough at it?

Dr Sean Brennan:

Oh they’re good enough at it, and not only that we have the technology to be able to sort of transmit the images to us. So yes, they’re good enough for us.

Norman Swan:

So you have a linked PAC system into Townsville?

Dr Sean Brennan:

We have a linked PAC system. But I think that you’ve touched on a very important thing there. I think that if one of the impacts here is that this is not a system that works by simply rolling it out and sitting back. It’s something that requires ongoing interaction and education. So particularly if you’ve got something like this if you’re requesting a CT scan from a slightly peripheral hospital to one whom you’re normally involved with, so you don’t have that working relationship with the radiologists for example, it’s absolutely imperative to set out what it is that you’re looking for. ‘Cause you don’t necessarily have that ability to sort of just to interactive with them on that term. So really everything that you do has to be functioning at a very high level if you want to get the maximum out of this for the patient.

Norman Swan:

‘Cause a good radiology practice would relish just doing something that’s a little bit different and higher quality if you want to ...

Dr Sean Brennan:

And I think also enjoys that interaction with the clinician.

Norman Swan:

Ian?.

Ian Roos:

Ian Roos, Chair of Cancer Voices Australia. Look I think congratulations are in order. I also think congratulations to the whole of this room. Ten years ago I conducted a study where I interviewed people who’d been affected by cancer, and some of them were in that North Queensland area, 600k round trip to Townsville, and the contrast between what is happening now and what was happening 10 years ago is immense. And I think this is one of the areas where people deserve congratulations in seeking to make life easier and better and a better journey for patients. So I think you in particular and a whole lot of other people in this room deserve congratulations for what you’re doing, and I’d like to encourage you to keep up that impetus and keep going.

Dr Sean Brennan:

Thank you sir, we’re delighted to do so. And if I may at this point please once again acknowledge the work of Doctor Sabe Sabesan and his colleagues who really were sort of the founding enthusiasts in North Queensland. So thank you very much.

Norman Swan:

Michael?

Michael Poulsen:

Yeah, Mike Poulsen in Queensland. We had a limited experience with telemedicine with clinics in Longreach and Charleville quite some time ago, and one of the real challenges we found was in the small peripheral hospitals, the medical staff rotated every six months, you know. You get another reliever through, the executive was constantly changing, the only constant force was the nurses, and we found that unless we involved the nurses in it, that it was very difficult to sort of maintain the momentum with it. I was wondering if you’ve had any experience with that?

Dr Sean Brennan:

Absolutely, it dovetails perfectly. And in fact that’s exactly what we find as well, is that very often the person who takes the initiative is one of the nursing staff, who's been there for a long time, who has a vested interest in her community.

Norman Swan:

And is the practitioner the medical super or is it that they’re own GP?

Dr Sean Brennan:

No, not necessarily, no, no, not necessarily, very often the medical super is the person providing a lot of the medical care in the area. So we do have that circumstance, but we also have rural GPs who come from their practice with their patient to be present in that consultation.

Norman Swan:

And have you identified the key nurses, and they are much more ...?

Dr Sean Brennan:

Yes, yes we have, yeah, yeah, we have. You know, in a sense they identify themselves.

Norman Swan:

‘Cause they demand it?

Dr Sean Brennan:

Because they become involved, so yes.

Norman Swan:

Sean, great talk, thank you very much indeed.

Dr Sean Brennan:

You’re very welcome, thank you.

(applause)
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