Communication and coordination: the keys to quality.

Numerous studies document disparities in cancer care based on race, and many extend this finding to ethnicity and socioeconomic status. Most highlight racial disparities in some aspect of cancer care delivery but fail to specify the mechanisms that lead to this pervasive phenomenon. Although such studies are valuable because they call attention to the magnitude of this problem, without elucidating the specific mechanisms that lead to disparities, they do not suggest interventions to eliminate them. In this issue of the Journal of Clinical Oncology, Ayanian et al describe results from a population-based survey of a multiethnic cohort of 1,067 colorectal cancer patients from Northern California. Patients completed surveys modified from the Picker Institute that reveal their perceptions of the quality of their cancer care. The surveys covered the core domains of access to care, symptom control, psychosocial support, health information, treatment specific information, confidence in providers, and coordination of care. Across all racial, ethnic, and linguistic groups, patients perceived access to information, psychosocial support, and care coordination to be the most deficient aspects of their care. African American, Hispanic, and other non–English-speaking patients reported significantly more problems with the quality of their care than white English speakers, and this was especially pronounced in the domains of communication and coordination of care. Despite the wealth of health information readily available in multiple media formats, these surveys reveal that patients desire better communication with their physicians. The study highlights the extent to which patients value having health information filtered, synthesized, and custom-tailored to their individual circumstances by a trusted physician. Communication refers specifically to information flow from physician to patient, and requires that a physician explain the diagnosis, prognosis, and therapeutic options in a comprehensible manner. Communication involves more than a oneway flow of information from physician to patient because it also requires that the physician listen to and incorporate patient preferences into formulation of a final treatment plan. Coordination of care involves facilitating patients’ access to the full complement of providers whose expertise may improve their outcomes or experience. It means ensuring that these providers have the necessary information available to formulate recommendations and then function as a team to deliver care. Thus, coordination itself focuses on communication and generally requires that one provider—typically the medical oncologist, but sometimes the surgeon—assume primary responsibility for orchestrating and overseeing all aspects of care. For many cancer patients, this requires more than simply a referral, but rather active engagement by the coordinating physician to ensure that other providers’ expertise is indeed obtained and that neither essential information nor the patient him or herself slips through the cracks. The survey by Ayanian et al reveals just how highly patients value physicians’ roles as coordinators. The eight items adapted from the Picker Institute survey ascertained the extent to which patients knew who was responsible for advising them about specific decisions and how often their providers seemed to be familiar with their problems, had communicated with one another, and had access to all necessary information. These issues of coordination are, of course, especially salient for cancer patients, whose care is typically shared by providers from multiple subspecialties often located at disparate practice sites. Given that colorectal cancer patients customarily undergo evaluation by gastroenterology, surgery, medical oncology, and often radiation oncology departments within the first few weeks of diagnosis, it is not surprising that coordination figures so prominently in a survey about quality of care. The finding that there are deficiencies in colorectal cancer care delivery and that there are racial disparities in perceived quality has been well documented previously by Ayanian and others. However, what is novel and especially important JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 23 NUMBER 27 SEPTEMBER 2