Lund Lars, Jønler Morten, Graversen Peder H, Borre Michael, Bro Flemming
Department of Urology, Central Hospital Unit, Region of Central Jutland.
Dan Med J. 2013 Aug;60(8):A4691.
Patients with prostate cancer (PC) have so far been followed in specialised hospital departments after diagnosis and initiation of treatment. The main obstacles associated with the transfer of this activity to general practice include lack of experience and uncertainty as to whether general practitioners (GPs) can handle follow-up.
A Steering Committee was established in collaboration with health-care professionals to devise a strategy for a shared care model. An action plan was designed that included 1) the development of a shared care model for follow-up and treatment, 2) implementation of the shared care model in cooperation between the parties involved, 3) design of procedures for re-referral, and 4) evaluation of effect, change processes and contextual factors.
A total of 2,585 patients with PC were included in the study: 1,172 had disseminated disease, 754 had no recurrence after curative treatment, 244 who had been treated with a curative intent were being treated for relapse, 186 underwent watchful waiting, 135 underwent active surveillance, while other scenarios applied in the remaining 94 cases. A total of 530 patients were transferred to follow-up with a GP and 2,055 were not transferred to their GP. The main reason why patients were considered not suitable for transfer to primary health care was the patients' own desire (33%), followed by clinical or biochemical disease progression (33%). The evaluation found that 96% of the patients were very comfortable with the permanent or temporary closure of the hospital course.
The project focused on factors that are essential for the successful transfer of responsibility for long-term follow-up of patients with prostate cancer. Patient transfer succeeded with high initial patient satisfaction.
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迄今为止，前列腺癌（PC）患者在诊断和开始治疗后一直由专科医院科室进行随访。将这项工作转移到普通医疗实践中的主要障碍包括经验不足以及对全科医生（GP）能否进行随访存在不确定性。
与医疗保健专业人员合作成立了一个指导委员会，以制定共享护理模式的策略。设计了一项行动计划，其中包括：1）制定随访和治疗的共享护理模式；2）相关各方合作实施共享护理模式；3）设计再次转诊程序；4）评估效果、变化过程和背景因素。
该研究共纳入2585例前列腺癌患者：1172例患有播散性疾病，754例在根治性治疗后无复发，244例接受根治性治疗后复发正在接受治疗，186例接受观察等待，135例接受主动监测，其余94例适用其他情况。共有530例患者被转至全科医生处进行随访，2055例未转至全科医生处。患者被认为不适合转至初级卫生保健的主要原因是患者自身的意愿（33%），其次是临床或生化疾病进展（33%）。评估发现，96%的患者对医院疗程的永久或临时结束非常满意。
该项目关注对成功转移前列腺癌患者长期随访责任至关重要的因素。患者转移成功，患者初始满意度较高。
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