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Table 2 Factors considered in melanoma follow-up that determined the use of shared care-a summary of melanoma clinicians’ perspective

From: Shared care in the follow-up of early-stage melanoma: a qualitative study of Australian melanoma clinicians’ perspectives and models of care

‘CONTINUING CARE’ factors Variables ‘COMMUNITY REFERRAL’ factors
Inclined melanoma unit clinicians towards specialist or ‘in-house’ follow-up e.g. by surgeon or melanoma unit dermatologist or melanoma GP   Inclined melanoma unit clinicians towards enabling follow-up by community doctors e.g. dermatologist, local GP or skin cancer clinic
▪ Higher risk of recurrence or new primary disease (prior melanoma, tumor thickness, ulceration, mitotic rate, family history, skin type, number of moles etc) Clinical ▪ Lower risk of recurrence or new primary disease
▪ Indications for extended post-surgical monitoring e.g. pain, hematomas, lymphodema, affected functioning
▪ Patient request for ‘in-house’ follow-up by someone with identified melanoma expertise Patient Psychosocial ▪ Proximity and travel to unit pose significant burdens; potential barrier for patient attending scheduled visits (live far away, have poor mobility etc)
▪ Patient allegiance to specialist with preference for attending with them personally
▪ Patient prefers follow-up with own family physician or local referring doctor, or happy to participate in shared care
▪ Patient very anxious; requires high emotional support and reassurance ▪ Patient organizes and coordinates follow-up with preferred providers and follow-up consistent with recommended schedule
▪ Patient uncomfortable with referral to local doctor for follow-up
▪ Patient knowledgeable, confident and conscientious in conducting skin self-examination
▪ Patient lackadaisical about skin surveillance and needs ongoing education and reinforcement of self examination
▪ Patient lives close by or is able and willing to travel to unit for appointments
▪ Emphasis on specialisation in follow-up; ie specialist training and/or location in melanoma unit to facilitate early detection of disease 1 Melanoma Clinician ▪ Professionally comfortable with sharing follow-up with non-specialist clinicians; especially when preferred by patient and/or addresses other psychosocial needs
▪ Sense of overall responsibility for ones patients; professional obligation to provide ongoing care or oversee quality of skin surveillance provided by others ▪ Sense of obligation to expand capacity of one’s practice to accommodate new melanoma patients
▪ Value of health system efficiency and maximizing benefits for greatest number of patients i.e. focusing specialist care for those at greatest need / highest risk
▪ Value of knowing patient well and patient-doctor rapport to facilitate education, early diagnosis and treatment ie doctor is familiar with patients’ skin, character, lifestyle, preferences; and patient comfortable to ask questions or return if worried
▪ Value of efficient care for individual patients i.e. reducing burdens of travel and cost of follow-up relative to clinical returns for those with lowest risk of disease
▪ Clinical interest in observing surgical and clinical outcomes over the long-term; being able to personally monitor developments
▪ Enjoyment of psychosocial aspects of follow-up ie regular contact with ‘well’ patients
▪ Professional courtesy and goodwill towards referring doctor; inclined to offer continued contribution to follow-up even if specialist in-put not clinically necessary
▪ Alternative follow-up with community doctor not available or accessible to patient Community Doctor ▪ Local doctor perceived to be knowledgeable, skilled and competent in providing melanoma follow-up 1
▪ Local doctor’s skills and interest in follow-up unknown; specialist feels need to supervise follow-up more closely
▪ Local doctor known to melanoma unit; eg has other successful shared care arrangements with specialist clinicians
▪ Patient has no or poor relationship with local doctors ▪ Local doctor known to be interested and motivated to conduct melanoma follow-up
▪ Specialist or patient perceive local doctor not to have the knowledge, skills, capacity or interest to conduct melanoma follow-up ▪ Patient has established good and trusting relationship with local doctor
▪ Value of research roles and responsibilities of specialist unit; benefits of longitudinal data on patient outcomes Organizational (melanoma unit) ▪ Limited capacity of specialist melanoma unit clinicians (surgical oncologists in particular) to provide long-term routine skin surveillance for patients at low risk of recurrence or new disease
▪ Institutional benefits of constituency and support-base for a specialist unit from maintaining ongoing relationships with current and past patients