Association of Follow-up Care Characteristics and Outcomes According to Number of Follow-up Providers Among Survivors of Hematologic Malignancies.

There is a critical need to have a better understanding of the role health providers play and the need to develop clinical tools to help clinicians identify patients who after completion of treatment for hematologic malignancies may benefit from a more intense follow-up care. The primary purpose of this study was to examine if number of follow-up providers (FUPs) - single versus multiple, influence healthcare utilization (HCU), quality of life and patient satisfaction at 6 months in a cohort of patients who completed treatment for hematologic malignancies. A secondary purpose was to evaluate characteristics of follow-up care that may identify patients at risk for urgent care or hospitalization within 6 months.

We utilized data from CANCER-CARES, a longitudinal prospective study of 928 patients with various cancers evaluating follow-up care after completing cancer treatment from a university-based hospital. This study was confined to 314 (52%) patients who had leukemia, lymphoma or multiple myeloma with available 6 month follow-up information. The cohort was divided according to the number of FUPs - single versus multiple. FUP is defined as a physician(s) responsible for managing any aspect of patient's health after cancer treatment. Single FUP may consist solely of a university or community oncologist or other physicians, while multiple FUP may be any combination of the above. Outcomes evaluated included healthcare utilization (HCU) - defined as an emergency room visit or hospitalization within 6 mos, quality of life (SF-12) and patient satisfaction (PSQ-18). Characteristics of follow-up care assocatied with HCU were determined using multivariate logistic regression. Factors determined to be predictive of HCU were assigned one point each. The summated score was used to represent the Follow-up Index Score (FUIS). We used the median FUIS of ≤ 2 to dichotomize the cohort to low vs high scores. The association of the FUIS according to single or multiple FUP with HCU was evaluated using multivariate logistic regression to adjust for patient characteristics.

Of the 314 patients, 214 (68%) sought follow-up care with a single FUP (80% remained with university providers, 20% moved back to community providers), while 100 (32%) sought follow-up care with multiple FUPs. Patients seen by single FUP were more likely to be older (median 59y vs 55y), live closer to their FUP (median 60 mi vs 150 mi), less likely to have prescription drug insurance (85% vs 94%), and were less likely to have undergone stem-cell transplantation. Patients seen by single FUP chose their physician more because of preference and quality of care than because of proximity, and were seen less frequently by their FUP as compared to the multiple FUPs. In addition, patients of single providers were seen shorter on their follow-up visits and were less likely to call their FUP with health-related questions. Five patterns of follow-up care were associated with HCU within 6 mos: 1) consult made for cancer-related problems, 2) consult made for other medical problems, 3) referral to another specialist, 4) call made to FUP for medical questions, and 5) ancillary procedures performed (ct, x-ray, ultrasound). In the multivariate analysis, patients seen by single or multiple FUP did not differ in HCU, quality of life and patient satisfaction. However, patients who were seen either by a single or multiple FUP and with low FUIS had significantly lower odds of HCU compared with single FUP with high FUIS [OR 0.11 (95%CI 0.05-0.25), p<0.001; OR 0.26 (95% CI 0.09-0.71), p<0.001) respectively. Patients seen by multiple FUP and have low FUIS also had lower odds of HCU compared with patients with multiple FUP and have high FUIS (OR 0.30, 95% CI 0.10-0.85, p<0.001). We failed to detect differences between patients seen by single or multiple FUPs with low FUIS. No differences in quality of life or patient satisfaction were noted.

In summary, patients with hematologic malignancies do not differ between patients who sought follow-up care from single or multiple FUP on HCU, quality of life or patient satisfaction. However, the FUIS shows potential to identify patients who may benefit from an intensive follow-up care plan geared towards preventing hospitalization because it demonstrated that high FUIS scores were associated with increased HCU within a 6 mo. period. The utility of the FUIS in predicting HCU between 6 and 12 months and in different types of malignancies should also be evaluated.

No relevant conflicts of interest to declare.