Inequities in Access: How Utilization of Palliative Radiation Therapy in British Columbia Varies with Geography

PurposeReferral and utilization rates are important measures of the quality of service offered by hospitals and clinics, specifically in regard to access to appropriate care. This study measured referral rates and utilization rates for palliative radiation therapy (PRT) for the different health authorities in British Columbia (BC), Canada, to establish areas where there were variations in access.Methods and MaterialsIncident data was taken from the British Columbia Cancer registry between 1986 and 1999. Radiation therapy (RT) data were extracted between 1986 and 2005. The extra years were included to allow time for any disease progression that may have occurred. Referral rates were defined as the percentage of incident cases that had a consultation at the British Columbia Cancer Agency. The PRT utilization rate was defined as the percentage of incident cases receiving at least one course of palliative radiation therapy. Data were analysed for each of the 16 Health Service Delivery Areas in BC.ResultsSignificant geographical variations in both referral rates and utilization rates were identified. Generally, both referral rates and utilization rates were lower in areas where there is limited or difficult access to a cancer centre. After building a cancer centre in the Interior region of BC, both referral and utilization rates increased.InterpretationUtilization of palliative radiation varies depending on where people live. Access to RT is lower in remote geographical areas, implying a barrier to essential health care services. This seems to be related to lower referral rates in those areas.     

A Comparison of Chronic Pain Between an Urban and Rural Population

A community-wide survey of 302 parents of 2-year-old children and 90 private medical practitioners in a large midwestern city revealed low immunization rates (31%) and differences in parent and provider perceptions of barriers to preschool immunizations. Parents most frequently identified barriers of system factors such as cost, lack of insurance coverage, and long office waits. System barriers were reported across differing sources of immunizations (private physician as well as public clinics) and were pervasive across income groups. Providers were more likely to report barriers of parental difficulties with forgetting immunizations or not knowing when the immunizations were due. Even though providers identified parental shortcomings with scheduling as problematic, only one fifth employed tracking and reminder systems. Implications of findings for modifications of the delivery of immunization services and for parent education are discussed.     

Music Therapy Reduces Pain in Palliative Care Patients: A Randomized Controlled Trial

ContextTreatment of pain in palliative care patients is challenging. Adjunctive methods of pain management are desirable. Music therapy offers a nonpharmacologic and safe alternative.ObjectivesTo determine the efficacy of a single music therapy session to reduce pain in palliative care patients.MethodsTwo hundred inpatients at University Hospitals Case Medical Center were enrolled in the study from 2009 to 2011. Patients were randomly assigned to one of two groups: standard care alone (medical and nursing care that included scheduled analgesics) or standard care with music therapy. A clinical nurse specialist administered pre- and post-tests to assess the level of pain using a numeric rating scale as the primary outcome, and the Face, Legs, Activity, Cry, Consolability Scale and the Functional Pain Scale as secondary outcomes. The intervention incorporated music therapist-guided autogenic relaxation and live music.ResultsA significantly greater decrease in numeric rating scale pain scores was seen in the music therapy group (difference in means [95% CI] ?1.4 [?2.0, ?0.8]; P < 0.0001). Mean changes in Face, Legs, Activity, Cry, Consolability scores did not differ between study groups (mean difference ?0.3, [95% CI] ?0.8, 0.1; P > 0.05). Mean change in Functional Pain Scale scores was significantly greater in the music therapy group (difference in means ?0.5 ([95% CI] ?0.8, 0.3; P < 0.0001).ConclusionA single music therapy intervention incorporating therapist-guided autogenic relaxation and live music was effective in lowering pain in palliative care patients.     

A Comparison of Perceptual and Reported Errors in Radiation Therapy

PurposeThe aims of this study are to investigate error perceptions in radiation therapy (RT), to analyze 13 years of reported errors by type and location, and to identify the similarities and differences between perceptual and reported errors.MethodClose-ended surveys were distributed to radiation therapists, RT students, medical physicists, and medical physicist residents at a large cancer centre. Two areas of relevance were: (1) to select the five most common categories of errors in radiation therapy and (2) to rank the many different stages where errors can be made in radiation therapy. The purpose of the survey was to investigate error perceptions based on type of error and location. The survey findings were compared to reported errors tabulated over 13 years (1998–2010) as collected by the Radiation Therapy Quality Assurance Committee on site. Frequency of survey responses and actual error occurrences were ranked and compared. Survey responses were analyzed by demographics based on gender, profession, and levels of experience. Statistical tests were also performed.ResultsThe total response rate for the survey was 45% (58 of 130 respondents). There is a consensus that documentation errors and treatment delivery errors occur most frequently. However, errors relating to bolus, geographic miss, and positioning device were outstanding in the perception of errors. Categories with high error frequencies for reported errors included field size, shielding, and monitor units calculation. There were no significant differences in survey responses based on demographics.ConclusionThe incongruence in certain types of errors between those perceived and those reported is alarming. When there is lack of awareness, the errors can be even more prone to occur. Patient safety culture starts from the individual; hence, understanding staff perception is critical in managing a quality assurance program. As technological advancements decrease certain errors, they may also have the potential to introduce new types of errors. Therefore, the last line of defense in any system remains qualified and attentive staff members.     

Sounds Vs. Patterns: A Case Comparison of Approaches for Articulation Therapy

Traditional sound-level approaches for remediation of multiple sound errors in children have several limitations. Approaches which focus on remediation of patterns of errors may be more effective in such cases; however, only sparse information is available on such approaches. In the present study a traditional (sound-level) program for articulation intervention was compared to a phonemic contrasting (pattern) program to determine which was more efficient in remediation of multiple sound errors demonstrated by one child. Three indices were employed to judge clinical efficiency: 1) number of trials required to complete the program, 2) improvement on an articulation test after each phase of the program, and 3) improvement in spontaneous speech after each phase of the program. Results indicated that the pattern approach was more efficient in all areas.     

Family Caregiver Quality of Life: Differences Between Curative and Palliative Cancer Treatment Settings

To compare the impact of cancer caregiving in curative and palliative settings on family caregiver quality of life (QOL), 267 family caregivers of cancer patients receiving curative treatment were compared to 134 family caregivers of cancer patients receiving palliative treatment through hospice. Both groups completed a demographic profile in addition to two self-report QOL questionnaires. Patient performance status and disease site were also recorded. Family caregivers of patients receiving palliative care had significantly lower QOL scores and lower scores on physical health. Hierarchical multiple regressions showed that after accounting for patient performance status, treatment status accounted for no additional significant variability in QOL scores. After accounting for caregiver level of education, treatment status accounted for no additional significant variability in physical health. These results suggest that the lower QOL scores of caregivers in the palliative setting are a reflection of the patients’ poorer performance status. The lower physical health scores of caregivers in the palliative setting appear to be a reflection of their lower educational level. Additional research is needed to evaluate the influence of specific demands of caregiving and emotional distress of the caregiver on caregiver QOL. J Pain Symptom Manage 1999;17:418–428.     

Delays in Palliative Care Referral Among Surgical Patients: Perspectives of Surgical Residents Across the State of Michigan

ContextPalliative care services (PCS) are underutilized and frequently delayed among surgical patients. Surgical residents often serve at the forefront for patient issues, including conducting conversations regarding prognosis and goals of care.ObjectivesThis qualitative study identifies critical barriers to palliative care referral among seriously ill surgical patients from the perspective of surgical residents.MethodsWe conducted semistructured interviews with surgical residents (n = 18) across the state of Michigan, which focused on experiences with seriously ill surgical patients and PCS. Inductive thematic analysis was used to establish themes based on the research objectives and data collected.ResultsFour dominant themes of resident-perceived barriers to palliative care referral were identified: 1) challenges with prognostication, 2) communication barriers, 3) respect for the surgical hierarchy, and 4) surgeon mentality. Residents consistently expressed challenges in predicting patient outcomes, and verbalizing this to both attendings and families augmented this uncertainty in seeking PCS. Communicative challenges included managing discordant provider opinions and the stigma associated with PCS. Finally, residents perceived that an attending surgeon's decisive authority and mentality negatively influenced the delivery of PCS.ConclusionsAmong resident trainees, unpredictable patient outcomes led to uncertainty in the timing and appropriateness of palliative care referral and further complicated communicating plans of care. Residents perceived and relied on the attending surgeon as the ultimate decision maker, wherein the surgeon's sense of responsibility to the patient was identified as a significant barrier to PCS referral. Further studies are needed to test surgeon-specific interventions to improve access to and delivery of PCS.     

Side Effects Associated with the Use of Intensity-Modulated Radiation Therapy in Breast Cancer Patients Undergoing Adjuvant Radiation Therapy: A Systematic Review and Meta-Analysis

PurposeThe purpose of the study was to establish the efficacy and safety of breast intensity-modulated radiation therapy (IMRT) compared with non-IMRT standard wedge radiation therapy (RT) for the treatment of adjuvant breast cancer.MethodsA systematic review and meta-analysis were completed using STATA and a random effects model. A total of 1,499 citations were identified from the literature search. Of those, 1,475 were excluded based on abstract review. Full texts of 24 remaining articles were reviewed and 11 articles were included in the final analysis. Side effects were analysed as the primary outcomes of interest. We calculated individual odds ratios and 95% confidence intervals for 17 classifications of side effects reported. The data for eight classifications of side effects were then pooled for meta-analyses to obtain more precise estimates of the relationships between adjuvant RT and a particular side effect.ResultsThe pooled analyses revealed potential protective associations between adjuvant IMRT and two acute side effects: dermatitis and moist desquamation. The remaining pooled estimates suggest that the odds of developing edema, hyperpigmentation, fat necrosis, pain, induration were no worse, nor better among those treated with IMRT compared with those treated with non-IMRT standard wedge RT.ConclusionThe pooled estimates from this meta-analysis are in line with the existing evidence. When the outcome of interest is reduction of the acute side effects: dermatitis and moist desquamation IMRT is a viable treatment option for women undergoing external beam RT after breast-conserving surgery.     

Risk Factors for Developing Prolonged Grief During Bereavement in Family Carers of Cancer Patients in Palliative Care: A Longitudinal Study

ContextFamily carers of palliative care patients report high levels of psychological distress throughout the caregiving phase and during bereavement. Palliative care providers are required to provide psychosocial support to family carers; however, determining which carers are more likely to develop prolonged grief (PG) is currently unclear.ObjectivesTo ascertain whether family carers reporting high levels of PG symptoms and those who develop PG disorder (PGD) by six and 13 months postdeath can be predicted from predeath information.MethodsA longitudinal study of 301 carers of patients receiving palliative care was conducted across three palliative care services. Data were collected on entry to palliative care (T1) on a variety of sociodemographic variables, carer-related factors, and psychological distress measures. The measures of psychological distress were then readministered at six (T2; n = 167) and 13 months postdeath (T3; n = 143).ResultsThe PG symptoms at T1 were a strong predictor of both PG symptoms and PGD at T2 and T3. Greater bereavement dependency, a spousal relationship to the patient, greater impact of caring on schedule, poor family functioning, and low levels of optimism also were risk factors for PG symptoms.ConclusionScreening family carers on entry to palliative care seems to be the most effective way of identifying who has a higher risk of developing PG. We recommend screening carers six months after the death of their relative to identify most carers with PG.