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Rapid Responses: Rapid Responses published:
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Nurse led care for cancer patients: beware of bias
- Max Mongelli, 119074 (19 November 2002)
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Is it a trial of nurse led follow up or of plenty time?
- Alan Rodger (15 December 2002)
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Max Mongelli, Associate Professor National University of Singapore, 119074
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Sirs, The attempt by Moore et al to assess the efficacy of a nurse led service for lung cancer patients is innovative and potentially cost- effective. Their conclusions however should be tempered by the presence of potential confounders that were not fully addressed in the discussion. The most obvious is a potential sex-preference bias by the mostly (75%) male patients for nurses as health care providers, and this may have been reflected in the patient satisfaction questionnaires. More problematic, but less evident, are the differences in the baseline characteristics shown in Table 1. There are more cases with co-morbidity in the intervention group, especially for cardiac and gastrointestinal diseases than in the controls. These differences may have arisen from the method of randomization, which is not fully described in this paper. The observed “earlier detection of symptomatic progression” in the nurse led group may have been due to differences in co-morbidity rather than the quality of care. Future studies in this area should ideally include different types of cancer. For small studies on this scale, greater attention should be placed in minimizing baseline differences, using minimization algorithms in the randomization procedure [1]. 1. MacRae KD, Treasure T. Minimisation: the platinum standard for trials? BMJ 1998;317:362-363 Competing interests: None declared |
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Alan Rodger, Professor of Radiation Oncology, Monash University Alfred Hospital, Melbourne, 3004, Australia
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Dear editors, The article by Ms Moore et al (1) comparing in a randomised trial nurse led follow up with medical led follow up of lung cancer patients reassures us that patients who agreed to be randomised to what they were offered as care were not disadvantaged and liked the experience. However, neither the print nor the e-version reassure me this trial was other than a study comparing open and frequent access to the same clinician against infrequent hurried consultations with a different registrar at each visit to the clinic. In nurse led care patients had 3 contacts per month while we are left to guess if medical led care provided more than the usual one visit every 2-3 months expected in the protocol. We are told nurse consultations lasted a mean of 23 mins. with a range of 2-120 mins. We again have to guess the length of medical visits but I bet they were very short. Lastly, does the increased use of radiotherapy and reduced use of chemotherapy (albeit not statistically significant for the latter) by nurses reflect the level of care or the specialties of the medical staff providing standard care? Science should be applied to follow up, but we cannot draw conclusions about patient and GP acceptability of this form of nurse led care compared with what was probably rushed and inadequate medical care. Yours sincerely, Alan Rodger. Reference: 1. Moore S , Corner J, Haviland J et al. Nurse led follow up and conventional medical follow up in management of patients with lung cancer: randomised trial. Br. Med. Journal 2002;325: 1145- 1147. Competing interests: None declared |
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