Principles of patient-centred care and barriers to their implementation: a case study of breast reconstruction in Australia

Abstract

Purpose

“Patient-centred care” is widely promoted as an ideal goal of health care systems, but is often difficult to achieve in practice. This article has three aims: to develop an original set of generalisable patient-centred care principles (PCCPs); to identify barriers to the implementation of these principles in a real-world setting, using breast reconstruction (BR) services in Australia as a case study; and to document examples of successful patient-centred care in relation to BR.

Methods

Semi-structured interviews (n = 90) were conducted with 31 breast and plastic reconstructive surgeons, 37 breast cancer health professionals and 22 women who underwent mastectomy as part of their breast cancer treatment and were dissatisfied with their BR experiences.

Results

Ten broad PCCPs were derived from our participant interviews. These principles comprised the following: maximising patient choice, access to services, patient and family support and appropriateness of information; minimising patient costs and physical and psychosocial morbidity; and facilitating informed decision-making, interdisciplinary patient management and evidence-informed practice. While the major barriers to the implementation of these PCCPs in relation to BR were resource driven, surgeon-related factors were also identified.

Conclusions

These PCCPs highlight areas of need but also provide examples of high quality patient-centred care. They may help to guide a national discussion about minimum standards of BR practice, while allowing for some necessary regional and cultural variation. They also have the potential to be applied more widely to the provision of a range of health services within Australia or internationally.

Appendices

Appendix 1. Issues concerning access to breast reconstruction in the Australian setting

Breast reconstruction (BR) is available in public and private hospitals in metropolitan and regional areas of Australia. Medicare Australia offers treatment as a public patient in a public hospital without cost to the patient, so BR performed by a surgeon appointed by the hospital is free of charge [27]. Medicare also covers 75% of the Medicare Benefits Schedule (MBS) fee for services and procedures for private patients in a public or private hospital [27], although the majority of surgeons will charge more than the schedule fee for BR (the “gap”) due to a lack of reasonable indexation of Medicare and health fund rebates over a number of decades.

Waiting times for delayed BR (DBR) are longer in public hospitals due mainly to limited availability of operating theatre time for these procedures, which are classified as Category 3 (non-urgent) surgery. National surgical waiting time guidelines state that Category 3 surgery “is desirable” within 12 months of being placed on a hospital waiting list [28], but wait times of up to 3–5 years are not uncommon [16]. If a woman has immediate BR (IBR) in a public hospital, then she can fast-track the initial reconstruction which, when performed at the same time as the mastectomy, should be completed within 30 days of the initial surgeon’s visit (Category 1).

In June 2015, 47% of the Australian population had some form of private patient hospital cover [27], but over 70% of BR is undertaken in private hospitals [13]. Waiting times for BR in private hospitals is minimal; however, significant out-of-pocket costs are associated with this surgery as the fees the surgeons charge are not regulated and even women with the top level of private health insurance face substantial additional costs for the surgeon, assistant surgeon and anaesthetist. The Breast Cancer Network of Australia (BCNA) has recently reported on out-of-pocket costs associated with breast cancer treatment [29]. The Minister for Health has responded by promising to introduce a more transparent system so that consumers can compare costs for common breast cancer tests and treatments against Medicare rebates before their surgery, as well as offering a guarantee that a Coalition government will provide full Medicare rebates for any breast cancer tests and treatments that are recommended by the Medical Services Advisory Committee [30].

Box 3 describes the two main models of surgeon involvement in BR in Australia.

Box 3 Main models of surgeon involvement in BR in Australia^a

Appendix 2

Table 3 Table of participants in the I-BREAST study

Appendix 3

Table 4 Interview content topics