Organization of services and nursing care: hospice and palliative medicine

The health care industry is changing and nursing case management is an integral part of restructured care in many institutions. Health care organizations must evaluate services and outcomes. The terminally ill comprise a large portion of patients in any health care delivery system. Hospitals that provide formal cancer care services need to evaluate where palliative care and hospice fit. Shifts in patient care will be evident due to changes in demographics, payor initiatives, and technological advances. Providing care for patients with advanced disease and the role of nursing have evolved over the past 10 years. One important area that has not changed is the passion and caring evident in the nurse's everyday practice.     

Using navigators to improve care of underserved patients: current practices and approaches

BACKGROUND: Logistic, cultural, educational, and other barriers can impede the delivery of high-quality cancer care to underserved patients. Patient navigation services represent one innovation for addressing perceived barriers to care encountered by disadvantaged patients. In this report, the authors have 1) defined patient navigation, distinguishing it from other cancer support services; 2) described how programs are organized; and 3) discussed the need for research on program effectiveness. METHODS: Information was examined on navigation programs published in the scientific literature and on line. Qualitative research also was conducted, consisting of direct observation of patient care in cancer clinics with and without navigators in northern California, in-person interviews with personnel and patients in the clinics observed, and telephone interviews with navigators at four sites across the United States. RESULTS: The authors found that navigation services have been implemented at all stages of cancer care: prevention, screening, treatment, and survival. Navigators differ from other cancer support personnel in their orientation toward flexible problem solving to overcome perceived barriers to care rather than the provision of a predefined set of services. There are no rigorous demonstrations of the effects and effectiveness of navigation, although such studies are underway. CONCLUSIONS: Currently, patient navigation is understudied, and literature documenting its effects and effectiveness is scant. Rigorous studies are needed of the navigator role and program costs and benefits. Such studies will facilitate an assessment of program effectiveness, feasibility across a range of health care settings, and performance relative to alternative approaches for addressing barriers to care among the underserved.     

Equitable access to cancer services: A review of barriers to quality care

BACKGROUND: Barriers to cancer care have been documented in nearly all settings and populations; such barriers represent potentially avoidable morbidity or mortality. A conceptual framework was used to describe patient, provider, and system barriers to cancer services. METHODS: A review of the English language literature on cancer care from 1980-1998 was conducted; key research was summarized for each domain in the conceptual model. RESULTS: Key patient barriers are related to old age, minority race, and low socioeconomic class; the common pathways by which these sociodemographic factors appear to mediate cancer outcomes include social class and race-related or class-related attitudes. Providers are often ill-prepared to communicate the complexities of cancer care to their diverse patient populations; constraints of the medical care system also can impede the delivery of care. To the authors' knowledge the impact of the rapid growth in managed care organizations (MCOs) on access to care has yet to be evaluated fully. Although MCOs historically have provided high levels of cancer screening in healthy populations, to the authors' knowledge there are fewer data regarding outcomes for elderly and poor populations and for treatment services. CONCLUSIONS: Additional research is needed to develop and test interventions to overcome barriers to care and evaluate the impact of the growth of managed care on access to cancer care for diverse populations.     

Proposed agenda for the measurement of quality-of-care outcomes in oncology practice.

Cancer is an important disease, and health care services have the potential to improve the quality and quantity of life for cancer patients. The delivery of these services also has recently been well codified. Given this framework, cancer care presents a unique opportunity for clinicians to develop and test outcome measures across diverse practice settings. Recently, the Institute of Medicine released a report reviewing the quality of cancer care in the United States and called for further development and monitoring of quality indicators. Thus, as we move into the 21st century, professional and regulatory agencies will be seeking to expand process measures and develop and validate outcomes-oriented measures for cancer and other diseases. For such measures to be clinically relevant and feasible, it is key that the oncology community take an active leadership role in this process. To set the stage for such activities, this article first reviews broad methodologic concerns involved in selecting measures of the quality of care, using breast cancer to exemplify key issues. We then use the case of breast cancer to review the different phases of cancer care and provide examples of phase-specific measures that, after careful operationalization, testing, and validation, could be used as the basis of an agenda for measuring the quality of breast cancer care in oncology practice. The diffusion of process and outcome measures into practice; the practicality, reliability, and validity of these measures; and the impact that these indicators have on practice patterns and the health of populations will be key to evaluating the success of such quality-of-care paradigms. Ultimately, improved quality of care should translate into morbidity and mortality reductions.     

The economic burden of prostate cancer,California, 1998

BACKGROUND: Prostate cancer is the most common malignancy diagnosed among men in the United States. This article reviews previous studies of the annual cost of all cancers and of prostate cancer in the United States and California and estimates the direct and indirect costs of prostate cancer in California in 1998. METHODS: Hospitalization costs, including costs of primary and secondary diagnoses of prostate cancer, were derived from the California Hospital Discharge data set (CHDS). Charges were converted to costs using hospital specific cost-to-charge ratios and an imputed cost for Health Maintenance Organization hospitalizations. Other direct medical costs were derived from the 1997 Medical Expenditure Panel Survey. Indirect mortality costs are the product of the number of deaths and the expected value of a male's future earnings taking into account age at death, earning patterns at successive ages, labor force participation, imputed value of housekeeping services, and a 3% discount rate. RESULTS: Prostate cancer direct health care costs in California were estimated at 180 million dollars, and lost productivity from premature death was estimated at 180 million dollars, for a total cost of 360 million dollars in 1998. The disease is largely one of older men; hospitalization costs account for three-fifths of total direct costs, and Medicare and private health insurance share almost equally in paying for hospital care. CONCLUSIONS: It is critical to identify cost-effective screening efforts that permit early detection of prostate cancer to reduce illness, premature deaths, and the high costs of prostate cancer.     

The design and implementation of a community breast cancer screening project.

A breast cancer screening program offers a community the opportunity to highlight and address an important health issue. This article has described the important elements of any such screening effort. To be successful, the program will require a multidisciplinary cadre of health care professionals working collaboratively throughout all phases of the planning, screening, and follow-up process. An agency should be identified to lead these professionals and monitor the progress of the screening effort. These screening programs can have direct and indirect benefits in the community. The direct benefits include improved access and delivery of health services, particularly those that meet state-of-the-art quality standards. The indirect benefits involve the promotion of breast cancer screening through education of women and providers about good breast health practices. As our experience in Michigan has shown, efforts featuring a broad coalition of forces can foster debate and discussion throughout the community and ultimately lead to improvements in the delivery of breast cancer screening services.     

Costs and trends in pancreatic cancer treatment

BACKGROUND:

Pancreatic cancer poses a substantial morbidity and mortality burden in the United States, and predominantly affects older adults. The objective of this study was to estimate the direct medical costs of pancreatic cancer treatment in a population‐based cohort of Medicare beneficiaries, and the contribution of different treatment modalities and health care services to the total cost of care and trends in costs over time.

METHODS:

In the linked Surveillance, Epidemiology, and End Results (SEER)‐Medicare database, pancreatic cancer patients were identified who were aged 66 years or older and who were diagnosed from 2000 to 2007. Total direct medical costs were estimated from Medicare payments overall and within categories of care. Costs attributable to pancreatic cancer were estimated by subtracting the costs of medical care in a matched cohort of cancer‐free beneficiaries.

RESULTS:

A total of 15,037 patients were identified, of whom 97% were observed from diagnosis until death. Mean total direct medical costs were $65,500. Mean total costs were greater for patients with resectable locoregional disease ($134,700) than for those with unresectable locoregional or distant disease ($65,300 and $49,000, respectively). Hospitalizations and cancer‐directed procedures collectively accounted for the largest fraction of health care costs. The total cost of care appeared to increase slightly over the study period (P = .05). The mean costs attributable to pancreatic cancer were $61,700.

CONCLUSIONS:

Despite poor prognosis and short survival, the economic burden of pancreatic cancer in the elderly is substantial. Demographic trends, greater use of targeted therapies, and possible implementation of screening strategies are likely to impact treatment patterns and costs in the future. Cancer 2012. © 2012 American Cancer Society.     

Gesundheitsökonomische Evaluation des Mammakarzinoms

Breast cancer is especially suitable as a model for health economics evaluations, since a wide range of procedures are available for diagnosis and therapy and the aims of treatment are well defined. At present, there are more than 1 million new cases of breast cancer per year worldwide, an increase of 23% since 1990. This has considerable implications for health economics, some of them difficult to quantify. It has been estimated that the total economic burden related to cancer amounts to 300–400 billion US$, 100–140 billion US$ of this being direct costs. In the United States of America, 15–20% of all direct costs of malignant disease are allocated to breast carcinoma, which amounted to 15–20 billion US$ in 2001.     

Diagnostic and therapeutic approaches for nonmetastatic breast cancer in Canada, and their associated costs

In an era of fiscal restraint, it is important to evaluate the resources required to diagnose and treat serious illnesses. As breast cancer is the major malignancy affecting Canadian women, Statistics Canada has analysed the resources required to manage this disease in Canada, and the associated costs. Here we report the cost of initial diagnosis and treatment of nonmetastatic breast cancer, including adjuvant therapies. Treatment algorithms for Stages I, II, and III of the disease were derived by age group (< 50 or > or = 50 years old), principally from Canadian cancer registry data, supplemented, where necessary, by the results of surveys of Canadian oncologists. Data were obtained on breast cancer incidence by age, diagnostic work-up, stage at diagnosis, initial treatment, follow-up practice, duration of hospitalization and direct care costs. The direct health care costs associated with 'standard' diagnostic and therapeutic approaches were calculated for a cohort of 17,700 Canadian women diagnosed in 1995. Early stage (Stages I and II) breast cancer represented 87% of all incident cases, with 77% of cases occurring in women > or = 50 years. Variations were noted in the rate of partial vs total mastectomy, according to stage and age group. Direct costs for diagnosis and initial treatment ranged from $8014 for Stage II women > or = 50 years old, to $10,897 for Stage III women < 50 years old. Except for Stage III women < 50 years old, the largest expenditure was for hospitalization for surgery, followed by radiotherapy costs. Chemotherapy was the largest cost component for Stage III women < 50 years old. This report describes the cost of diagnosis and initial treatment of nonmetastatic breast cancer in Canada, assuming current practice patterns. A second report will describe the lifetime costs of treating all stages of breast cancer. These data will then be incorporated into Statistics Canada's Population Health Model (POHEM) to perform cost-effectiveness studies of new therapeutic interventions for breast cancer, such as the cost-effectiveness of day surgery, or of radiotherapy to all breast cancer patients undergoing breast surgery.     

Exploring the economic impact of breast cancers during the 18 months following diagnosis

The economic impact on individuals with breast cancer is not well understood. We sought to identify and describe the direct and indirect economic losses to breast cancer survivors in Australia. A longitudinal, population-based study of 287 women was used to explore economic outcomes (costs and lost income) for women with breast cancer 0-18 months post-diagnosis. Survey methods collected data on out-of-pocket costs, care-giving support, paid and unpaid work reductions, and perceptions from participants on these financial impacts. Bootstrapping was used to estimate 95% confidence intervals around means. Data were sub-grouped by cost type, age category and disease severity. Lost income, health service expenditures and lost unpaid work were the greatest sources of economic burden. Women with positive lymph nodes reported significantly higher costs than those with negative lymph nodes (US$6674 versus US$3533, p<0.001), and younger women (< or =50 years) with positive lymph nodes experienced costs 80% greater than older women (US$8880 versus US$4937, p<0.001). Economic costs related to breast cancer may continue to affect women 18 months post-diagnosis. Economic research adds an important dimension for understanding the impact of breast cancer, and findings may be used to help improve supportive care services for women and families confronted by this disease.     

Provision of oncology services in remote rural areas: a Scottish perspective

There is a paucity of research into rural health care services. In particular little is known about the provision of specialist cancer services for patients who live in remote rural areas of the UK. This study set out to investigate current models of medical and clinical oncology care in Scotland. A national survey with key health professionals was conducted to identify rural oncology schemes currently in operation. Detailed quantitative data about the schemes together with qualitative data on how health professionals view current models of care were collected by a computer-assisted telephone survey. Schemes that currently provide outpatient and chemotherapy oncology services for remote rural patients fell into three categories: central clinics (5); shared care outreach clinics with chemotherapy provision (11); and shared care outreach clinics without chemotherapy provision (7). All radiotherapy was conducted at central clinics (5). Widely varying practices in delivery of cancer care were found across the country. The main issues for professionals about current models of care involved expertise, travelling and accessibility (for patients), communication and expansion of the rural service. Nation-wide consistency in cancer care has still to be achieved. Travelling for treatment was seen to take its toll on all patients but particularly for the very remote, elderly and poor. Most professionals believe that an expansion of rural services would be of benefit to these patients. It is clear, however, that the proper infrastructure needs to be in place in terms of local expertise, ensured quality of care, and good communication links with cancer centres before this could happen.     

Implementing personalized pathways for cancer follow-up care in the United States: Proceedings from an American Cancer Society–American Society of Clinical Oncology summit

A new approach to cancer follow-up care is necessary to meet the needs of cancer survivors while dealing with increasing volume and provider shortages, knowledge gaps, and costs to both health care systems and patients. An approach that triages patients to personalized follow-up care pathways, depending on the type(s) and level(s) of resources needed for patients’ long-term care, is in use in the United Kingdom and other countries and has been shown to meet patients’ needs, more efficiently use the health care system, and reduce costs. Recognizing that testing and implementing a similar personalized approach to cancer follow-up care in the United States will require a multipronged strategy, the American Cancer Society and the American Society of Clinical Oncology convened a summit in January 2018 to identify the needed steps to move this work from concept to implementation. The summit identified 4 key strategies going forward: 1) developing a candidate model (or models) of care delivery; 2) building the case for implementation by conducting studies modeling the effects of personalized pathways of follow-up care on patient outcomes, workforce and health care resources, and utilization and costs; 3) creating consensus-based guidelines to guide the delivery of personalized care pathways; and 4) identifying and filling research gaps to develop and implement needed care changes. While these national strategies are pursued, oncology and primary care providers can lay the groundwork for implementation by assessing their patients’ risk of recurrence and the chronic and late effects of cancer as well as other health care needs and resources available for care and by considering triaging patients accordingly, referring patients to appropriate specialized survivorship clinics as these are developed, helping to support patients who are capable of self-managing their health, setting expectations with patients from diagnosis onward for the need for follow-up in primary care and/or a survivorship clinic, and improving coordination of care between oncology and primary care.     

Cost of care for patients in cancer clinical trials

BACKGROUND: Information on the costs of medical care for patients enrolled in clinical trials is needed by policymakers evaluating ways to facilitate clinical research in a managed care environment. We examined the direct costs of medical care for patients enrolled in cancer clinical trials at a large health maintenance organization (HMO). METHODS: Costs for 135 patients who entered 22 cancer clinical trials (including 12 breast cancer trials) at Kaiser Permanente in Northern California, from 1994 through 1996 were compared with costs for 135 matched control subjects who were not enrolled in such trials. Cancer registry data and medical charts were used in matching the control subjects to the trial enrollees with respect to cancer site, stage, date of diagnosis, age, sex, and trial eligibility. The direct costs of medical care were compared between trial enrollees and the control subjects for a 1-year period, with data on costs and utilization of services obtained from Kaiser Permanente databases and medical charts. RESULTS: Mean 1-year costs for the enrollees in trials were 10% higher than those for the control subjects ($17 003 per enrollee compared with $15 516 per control subject; two-sided P =.011). The primary component of this difference was a $1376 difference in chemotherapy costs ($4815 per trial enrollee versus $3439 per control subject; two-sided P<.001). Costs for the 11 enrollees in trials that had a bone marrow transplant (BMT) arm were approximately double the costs for their matched control subjects (borderline significance: two-sided P=.054). The $15 041 mean cost for the enrollees in trials without BMT was similar to the $15 186 mean cost for their matched control subjects. CONCLUSIONS: Participation in cancer clinical trials at a large HMO did not result in substantial increases in the direct costs of medical care.     

Equitably improving outcomes for cancer survivors and supporting caregivers: A blueprint for care delivery,research, education,and policy

Cancer care delivery is being shaped by growing numbers of cancer survivors coupled with provider shortages, rising costs of primary treatment and follow-up care, significant survivorship health disparities, increased reliance on informal caregivers, and the transition to value-based care. These factors create a compelling need to provide coordinated, comprehensive, personalized care for cancer survivors in ways that meet survivors’ and caregivers’ unique needs while minimizing the impact of provider shortages and controlling costs for health care systems, survivors, and families. The authors reviewed research identifying and addressing the needs of cancer survivors and caregivers and used this synthesis to create a set of critical priorities for care delivery, research, education, and policy to equitably improve survivor outcomes and support caregivers. Efforts are needed in 3 priority areas: 1) implementing routine assessment of survivors’ needs and functioning and caregivers’ needs; 2) facilitating personalized, tailored, information and referrals from diagnosis onward for both survivors and caregivers, shifting services from point of care to point of need wherever possible; and 3) disseminating and supporting the implementation of new care methods and interventions.     

Responding to Acute Care Needs of Patients With Cancer: Recent Trends Across Continents

Remarkable progress has been made over the past decade in cancer medicine. Personalized medicine, driven by biomarker predictive factors, novel biotherapy, novel imaging, and molecular targeted therapeutics, has improved outcomes. Cancer is becoming a chronic disease rather than a fatal disease for many patients. However, despite this progress, there is much work to do if patients are to receive continuous high-quality care in the appropriate place, at the appropriate time, and with the right specialized expert oversight. Unfortunately, the rapid expansion of therapeutic options has also generated an ever-increasing burden of emergency care and encroaches into end-of-life palliative care. Emergency presentation is a common consequence of cancer and of cancer treatment complications. It represents an important proportion of new presentations of previously undiagnosed malignancy. In the U.K. alone, 20%–25% of new cancer diagnoses are made following an initial presentation to the hospital emergency department, with a greater proportion in patients older than 70 years. This late presentation accounts for poor survival outcomes and is often associated with poor patient experience and poorly coordinated care. The recent development of acute oncology services in the U.K. aims to improve patient safety, quality of care, and the coordination of care for all patients with cancer who require emergency access to care, irrespective of the place of care and admission route. Furthermore, prompt management coordinated by expert teams and access to protocol-driven pathways have the potential to improve patient experience and drive efficiency when services are fully established. The challenge to leaders of acute oncology services is to develop bespoke models of care, appropriate to local services, but with an opportunity for acute oncology teams to engage cancer care strategies and influence cancer care and delivery in the future. This will aid the integration of highly specialized cancer treatment with high-quality care close to home and help avoid hospital admission.

Implications for Practice:

Emergency presentations of cancer patients to health care services can be associated with high risks and poor outcomes. Systematic approaches are described to create best practice for these patients based on expert teams and careful organization of services in all hospitals. These approaches, called “acute oncology” in the U.K., may improve care and avoid unnecessary deaths.     

Bending the Cost Curve in Childhood Cancer

Healthcare for children with cancer costs significantly more than other children. Cost reduction efforts aimed toward relatively small populations of patients that use a disproportionate amount of care, like childhood cancer, could have a dramatic impact on healthcare spending. The aims of this review are to provide stakeholders with an overview of the drivers of financial costs of childhood cancer and to identify possible directions to curb or decrease these costs. Costs are incurred throughout the spectrum of care. Recent trends in pharmaceutical costs, evidence identifying the contribution of administration costs, and overuse of surveillance studies are described. Awareness of cost and value, i.e., the outcome achieved per dollar or burden spent, in delivery of care and research is necessary to bend the cost curve. Incorporation of these dimensions of care requires methodology development, prioritization, and ethical balance.     

Promoting cancer screening within the patient centered medical home

While consensus has grown that primary care is the essential access point in a high-performing health care system, the current model of primary care underperforms in both chronic disease management and prevention. The Patient Centered Medical Home model (PCMH) is at the center of efforts to reinvent primary care practice, and is regarded as the most promising approach to addressing the burden of chronic disease, improving health outcomes, and reducing health spending. However, the potential for the medical home to improve the delivery of cancer screening (and preventive services in general) has received limited attention in both conceptualization and practice. Medical home demonstrations to date have included few evidence-based preventive services in their outcome measures, and few have evaluated the effect of different payment models. Decreasing use of hospitals and emergency rooms and an emphasis on improving chronic care represent improvements in effective delivery of healthcare, but leave opportunities for reducing the burden of cancer untouched. Data confirm that what does or does not happen in the primary care setting has a substantial impact on cancer outcomes. Insofar as cancer is the leading cause of death before age 80, the PCMH model must prioritize adherence to cancer screening according to recommended guidelines, and systems, financial incentives, and reimbursements must be aligned to achieve that goal. This article explores capacities that are needed in the medical home model to facilitate the integration of cancer screening and other preventive services. These capacities include improved patient access and communication, health risk assessments, periodic preventive health exams, use of registries that store cancer risk information and screening history, ability to track and follow up on tests and referrals, feedback on performance, and payment models that reward cancer screening.     

Direct medical cost associated with colorectal cancer in north of Jordan

Colorectal cancer (CRC) is mainly characterized as the malignant and impaired growth of rectal cells in the intestinal region. Direct medical cost is related to resources, which are directly used in treating the patient, that mainly includes the cost of drugs, diagnostic, treatment, follow-up, rehabilitation, and hospital admission. The objective of this study is to estimate and analyze direct medical costs attributable to CRC in Jordan. A retrospective analysis of a cohort patients treated for CRC data has been performed to determine direct medical costs attributable to CRC in Jordan. The prevalence-based approach has been used in addition to the “bottom up” approach to accumulate 1-year time costs of CRC. Demographic, clinical, and economic data have been collected and analyzed using SPSS for windows. Costs were estimated by a bottom-up approach, in which each service component was identified and valued at the most detailed level, to provide greater transparency and reliability in economic evaluation of health care services. This study quantified the economic burden associated with CRC by Jordanian patients in King Abdullah University Hospital from the perspective of health care providers (public sector). Total CRC cost in the year 2014 was estimated to JD 695,608, and the most expensive stage for all sites was stage 4 reaching a cost of JD 5147. Advanced disease stages were associated with an increase in total cost and chemotherapy costs. In conclusion, results of this study propose that direct medical costs associated with CRC are considerable. Most of the cost was devoted for medications, primarily chemotherapy. Advanced stages were associated with higher cost and largest number of patients.     

Enhancing global access to cancer medicines

Globally, cancer is the second leading cause of death, with numbers greatly exceeding those for human immunodeficiency virus/acquired immunodeficiency syndrome, tuberculosis, and malaria combined. Limited access to timely diagnosis, to affordable, effective treatment, and to high-quality care are just some of the factors that lead to disparities in cancer survival between countries and within countries. In this article, the authors consider various factors that prevent access to cancer medicines (particularly access to essential cancer medicines). Even if an essential cancer medicine is included on a national medicines list, cost might preclude its use, it might be prescribed or used inappropriately, weak infrastructure might prevent it being accessed by those who could benefit, or quality might not be guaranteed. Potential strategies to address the access problems are discussed, including universal health coverage for essential cancer medicines, fairer methods for pricing cancer medicines, reducing development costs, optimizing regulation, and improving reliability in the global supply chain. Optimizing schedules for cancer therapy could reduce not only costs, but also adverse events, and improve access. More and better biomarkers are required to target patients who are most likely to benefit from cancer medicines. The optimum use of cancer medicines depends on the effective delivery of several services allied to oncology (including laboratory, imaging, surgery, and radiotherapy). Investment is necessary in all aspects of cancer care, from these supportive services to technologies, and the training of health care workers and other staff.     

Building infrastructure for cancer research in Africa

Cancer incidence in Africa is increasing as a result of aging populations, lifestyle changes, and improved detection. However, cancer etiology, prevention, and control in Africa are poorly understood, and survival rates from cancer are among the lowest in the world. Poor cancer survival suggests that improvements in health care, patient education, and relevant research are critically needed. An increase in research infrastructure is required to achieve adequate screening, diagnosis, and treatment of cancer in Africa. While research is a basis for clinical practice and policy changes in resource-abundant areas, the research infrastructure in Africa is deficient in many areas. Building infrastructure for research includes creating supportive environments for research endeavors, securing funding for resources and research personnel, developing training and mentorship opportunities, and building collaborative research with other institutions. Goals for the development of cancer research in Africa may include research on cancer incidence and mortality, cancer etiology and risk factors, clinical research with a focus on early diagnosis/ treatment and palliative care, health economics, and community-based participatory research. An understanding of the environmental and cultural framework by which cancer is diagnosed and managed is critical for developing interventions that will be effective in African populations.