An algorithmic approach to clinical decision making

Nursing care often jumps from problem identification to proposed interventions, bypassing information gathering and inclusion of all pertinent clinical factors. To promote improvement in medical oncology patient outcomes, two algorithms were developed. Algorithm use does not guarantee a positive outcome, but it does ensure that a standard of care appropriate to a clinical problem will be instituted. Two algorithms for commonly encountered problems of elevated body temperature (hyperthermia) and fluid volume excess are presented. When used, they demonstrated that this purposeful method of decision making led to a more thorough patient assessment and a more informed nursing response. Any or all of these outcomes ultimately result in better patient management.     

Construction of clinical algorithms for educational programs

Clinical algorithms have been used successfully in a variety of health care settings to assist health care professionals in the diagnosis and management of medical problems. In addition to their clinical applications, algorithms also serve as an instructional resource by themselves and when used in conjunction with other educational methodologies. A recommended algorithm development process is described for cancer educators who wish to take advantage of the unique contribution clinical algorithms can offer for their educational programs. Algorithm design conventions are reviewed and specific writing suggestions are offered for the guidance of educators who want to design their own clinical algorithms. Objections to clinical algorithms can often be attributed to a misunderstanding of their proper role, which is to facilitate, not dictate, the decision process and guide the application of management logic. Clinical algorithms are a valuable instructional resource that can be used in a wide range of educational settings from self-instruction units to the design of lecture presentations.     

Significance of radiographic splenic vessel involvement in the pancreatic ductal adenocarcinoma of the body and tail of the gland

Follow-up of the melanoma patient involves many different methods of surveillance. Specific guidelines for modalities and frequency are flexible and largely open to physician preference. Patient education and self-examination are generally viewed as crucial and cost-effective for recurrence detection. Increased frequency of clinical follow-up, laboratory studies, and imaging has not demonstrated survival benefit in surveillance. However, appropriate application of these different methods is controversial and evolving, especially with changing surgical management and new medical therapies.     

Clinical and economic effects of central venous catheters on oncology patient care

Central Venous Catheters (CVC) and ports are essential devices to the medical care of cancer patients. Every year about one million CVCs are inserted in cancer patients. The field of oncohematology is making a great contribution to the development of new models of catheters and to the use of innovative materials. New therapeutic protocols, based on continuous administration and higher doses of anticancer drugs with relative phlebitis problems, have raised the issue of long CVC in situ permanence. Different complications are related to the intravascular catheters such as those associated with insertion (pneumothorax, damages to arteries and nerves), or with the duration of catheterization (thrombosis and infections). Furthermore, Catheter-Related Bloodstream Infections (CRBSI), in particular, cause significant mortality and excessive hospital costs. The aim of this prospective study was to analyze the costs related to the use of polyurethane (PU) CVC. 44 patients with a non tunneled double lumen PU CVC in place were followed for 6 months, and for each patient, time of permanence, possible antibiotic prophylaxis, blood parameters, adverse events and medical treatments were monitored. Our results suggest that physicians should pay greater attention to the correlation between new medical devices and the real benefit for the patient, and economic consequences.     

Direct costs associated with the disease management of patients with unresectable advanced non-small-cell lung cancer in The Netherlands

INTRODUCTION: Disease management and costs of treatment of patients with unresectable advanced non-small-cell lung cancer (NSCLC) in The Netherlands are not well known. METHODS: A retrospective medical chart review was performed by collecting data from the time of diagnosis until the time of death or the end of the evaluation period. In addition to the demographic data, information was collected on the overall management of the patient. Hospital resource utilisation data collected included number of outpatient specialist visits, number and length of hospitalisation, type and number of diagnostic and laboratory procedures, type and number of radiotherapy cycles and detailed information on chemotherapy. To evaluate the economic impact of second-line treatment, a distinction was made between patients who received only best supportive care (BSC, group A) and those who received chemotherapy as a second-line treatment in addition to BSC (group B). The study was performed from the hospital perspective and reports on 2005 costs. RESULTS: Of 102 patients, 74 belonged to group A and 28 to group B. Patient management included a multidisciplinary approach, the extent of which depended on symptoms of the disease and presence of metastases. The average total treatment cost per patient per year of unresectable advanced NSCLC in The Netherlands was euro32,840 in group A and euro31,187 in group B. In both groups, hospitalisation was the major cost driver. In group B second-line chemotherapy was the second largest contributor of the costs. In spite of the difference in numbers of treatment lines provided to patients in groups A and B the total average costs per patient per year were comparable. Overall, the management of unresectable advanced NSCLC appeared to conform with current guidelines in The Netherlands. CONCLUSION: These patients show high medical resource consumption, with hospitalisation being the main cost driver in both groups. As economic arguments are becoming increasingly important in medical decision making on both national and local levels, this information is relevant for both policy makers and specialists. These data can also be used in future research to evaluate the economic impact of new therapies in NSCLC, especially of those that aim to treat patients in an outpatient setting.     

Positron emission tomography in initial staging and diagnosis of persistent or recurrent disease

Positron emission tomography (PET) constitutes a major advance in the diagnosis, staging, prognostic assessment, and follow-up of lung cancer. However, it is not a magic bullet that can solve all of the uncertainties that beguile the imaging of this disease. Small lesions, particularly those in the brain, may often be missed with PET, and three-dimensional localization of suspected sites may also be unreliable. We are still learning how best to apply this new technology in an environment that demands the efficient use of medical resources. PET will probably be used most enthusiastically in the prethoracotomy staging of patients who are considered operable or probably operable on the basis of computed tomography and in the assessment of treatment response and disease recurrence when clinical management will be determined by prompt recognition of these events.     

Statin as a therapeutic agent in gastroenterological cancer

Statins inhibit 3-hydroxy-3-methylglutaryl-CoA reductase, the rate-limiting enzyme of the mevalonate pathway, and are widely used as an effective and safe approach handle hypercholesterolemia. The mevalonate pathway is a vital metabolic pathway that uses acetyl-CoA to generate isoprenoids and sterols that are crucial to tumor growth and progression. Multiple studies have indicated that statins improve patient prognosis in various carcinomas. Basic research on the mechanisms underlying the antitumor effects of statins is underway. The development of new anti-cancer drugs is progressing, but increasing medical costs from drug development have become a major obstacle. Readily available, inexpensive and well-tolerated drugs like statins have not yet been successfully repurposed for cancer treatment. Identifying the cancer patients that may benefit from statins is key to improved patient treatment. This review summarizes recent advances in statin research in cancer and suggests important considerations for the clinical use of statins to improve outcomes for cancer patients.     

Cost analysis of lung cancer management in South Western Sydney

Introduction: Lung cancer is the leading cause of cancer mortality in Western nations, and associated health‐care costs are escalating. The aim of this study was to describe the current pattern of resource use and direct medical costs associated in managing lung cancer in South Western Sydney, Australia. Methods: All new cases of primary lung carcinoma discussed at the Liverpool and Macarthur Cancer Therapy Centre (CTC) Lung Cancer Multidisciplinary Team meeting or seen at CTC between 1 December 2005 and 21 December 2006 were reviewed. Staging investigations, hospitalisation, treatment and follow‐up investigations were documented from first consultation to last follow‐up (31 October 2008 or death). Cost estimates were based on the Australian Medicare Benefits Schedule and reported in Australian dollars. Infrastructure, staff and non‐medical costs were excluded. Results: There were 210 patients, median age 68.2 years (range 39–90) with median follow‐up of 16.6 months. The pathology and stage distribution were: 3.8% limited stage small cell lung cancer (SCLC), 10.0% extensive stage SCLC, 13.4% stage I and II non‐small cell lung cancer (NSCLC), 28.5% stage III NSCLC and 44.3% stage IV NSCLC. The estimated total cost for managing this patient cohort was A$2.91 million. The cost components were: staging investigations (10.1%), treatment 41.2% (2.8% surgery, 15.8% radiotherapy and 22.6% chemotherapy), hospitalisation (43.7%) and follow‐up investigations (5%). The median costs for managing NSCLC and SCLC subgroups were A$10 675 (range A$669–612 789) and A$14 799 (range A$908–31 057), respectively. Conclusion: Hospitalisation and cancer treatment, particularly chemotherapy, accounted for the major components of direct medical costs in the management of lung cancer.     

Development of an evidence‐based guideline for imaging in cervical spine trauma

Cervical spine trauma is a common reason for presentation to an emergency department. However, less than 5% of patients who have suffered possible neck injury actually have an injury requiring medical treatment. Nevertheless, the consequences, both for the patient and the doctor, of a missed injury are well recognized by emergency department medical staff. This results in the vast majority of these patients receiving some form of diagnostic imaging. We describe the development of an evidence‐based imaging guideline for use in the patient who has suffered cervical spine trauma. The guideline aims to help clinicians determine, at the bedside, when it is appropriate to use imaging and which imaging modality should be used first. Correct utilization of the guideline should lead to a reduction in the number of imaging tests required to reach a diagnosis without adverse patient outcomes.     

The cost of systemic therapy for metastatic colorectal carcinoma in Slovenia: discrepancy analysis between cost and reimbursement

Background.

The aim of the study was to estimate the direct medical costs of metastatic colorectal cancer (mCRC) treated at the Institute of Oncology Ljubljana and to question the healthcare payment system in Slovenia.

Methods.

Using an internal patient database, the costs of mCRC patients were estimated in 2009 by examining (1) mCRC direct medical related costs, and (2) the cost difference between payment received by Slovenian health insurance and actual mCRC costs. Costs were analysed in the treatment phase of the disease by assessing the direct medical costs of hospital treatment with systemic therapy together with hospital treatment of side effects, without assessing radiotherapy or surgical treatment. Follow-up costs, indirect medical costs, and nonmedical costs were not included.

Results.

A total of 209 mCRC patients met all eligibility criteria. The direct medical costs of mCRC hospitalization with systemic therapy in Slovenia for 2009 were estimated as the cost of medications (cost of systemic therapy + cost of drugs for premedication) + labor cost (the cost of carrying out systemic treatment) + cost of lab tests + cost of imaging tests + KRAS testing cost + cost of hospital treatment due to side effects of mCRC treatment, and amounted to €3,914,697. The difference between the cost paid by health insurance and actual costs, estimated as direct medical costs of hospitalization of mCRC patients treated with systemic therapy at the Institute of Oncology Ljubljana in 2009, was €1,900,757.80.

Conclusions.

The costs paid to the Institute of Oncology Ljubljana by health insurance for treating mCRC with systemic therapy do not match the actual cost of treatment. In fact, the difference between the payment and the actual cost estimated as direct medical costs of hospitalization of mCRC patients treated with systemic therapy at the Institute of Oncology Ljubljana in 2009 was €1,900,757.80. The model Australian Refined Diagnosis Related Groups (AR-DRG) for cost assessment in oncology being currently used is probably one of the reasons for the discrepancy between pay-outs and actual costs. We propose new method for more precise cost assessment in oncology.     

Radiomics: extracting more information from medical images using advanced feature analysis

Solid cancers are spatially and temporally heterogeneous. This limits the use of invasive biopsy based molecular assays but gives huge potential for medical imaging, which has the ability to capture intra-tumoural heterogeneity in a non-invasive way. During the past decades, medical imaging innovations with new hardware, new imaging agents and standardised protocols, allows the field to move towards quantitative imaging. Therefore, also the development of automated and reproducible analysis methodologies to extract more information from image-based features is a requirement. Radiomics--the high-throughput extraction of large amounts of image features from radiographic images--addresses this problem and is one of the approaches that hold great promises but need further validation in multi-centric settings and in the laboratory.     

Améliorer la prise en charge des patients dans les services d’imagerie médicale en oncologie

The development of cancer is monitored through a range of imaging examinations. The radiologist is often the one who first discovers anomalies and has to break the news. The task is all the more difficult since he/she does not receive any specific training in the management of such difficult situations. There is a great risk of inappropriate responses. The protocols which have been proposed in the literature are primarily aimed at referring physicians, in particular oncologists. We proposed a protocol, CREDO, more appropriate to the everyday practice of medical imaging, in particular in oncology. Even if we have the best ideals and intentions, there is a great need for professionals to examine and improve doctor-patient interactions, in dealing with patient’s need for information.     

The economics of high-technology medical imaging

The field of high-technology medical imaging equipment and methods have recently received undue negative attention in the battle against sharply increasing health-care costs. This article identifies numerous imaging methods and examines the field's vulnerable areas such as high capital equipment costs and subsequent high operating costs. Comparison is drawn between the cost of high-tech medical imaging and the total cost of health care. The multiple benefits of medical imaging to the practice of medicine in relation to its total cost are also discussed. Evidence is presented to support the view of Dr. D. MacEwan, former president of the Radiological Society of North America: "High-technology imaging devices do not have to increase the cost of health care and can actually save money if passed judiciously." This conclusion was reached from a 13-year study examining the health-care records of more than one million Manitobans.     

Molecular imaging and personalized medicine: an uncertain future

The Food and Drug Administration has described their view of the role that imaging will play in the approval, and perhaps postapproval, use of new therapeutic drugs. The therapeutic drug industry and regulatory authorities have turned to imaging to help them achieve better efficiency and efficacy. We must extend this initiative by demonstrating that molecular imaging can also improve the efficiency and efficacy of routine treatment with these same drugs. The role of molecular imaging in personalized medicine, using targeted drugs in oncology, is very attractive because of the regional information that it provides (in many cases, with a functional or dynamic component), which cannot be provided by in vitro methods ("regional proteomics"). There is great potential for molecular imaging to play a major role in selecting appropriate patients and providing early proof of response, which is critical to addressing the conflict between the high price of treatment and limited reimbursement budgets. This is a new venture in both molecular imaging and targeted drugs. However, there are various regulatory, financial, and practical barriers that must be overcome to achieve this aim, in addition to the normal scientific challenges of drug discovery. There is an urgent need to reduce the cost (i.e., time and money) of developing imaging agents for routine clinical use. The mismatch between the current regulations and personalized medicine includes molecular imaging and requires the engagement of the regulatory authorities to correct. Therapeutic companies must be engaged early in the development of new targeted drugs and molecular imaging agents to improve the fit between the two drug types. Clinical trials must be performed to generate data that not only shows the efficacy of imaging plus therapy in a medical sense, but also in a financial sense. Molecular imaging must be accepted as not just good science but also as central to routine patient management in the personalized medicine of the future.     

Principles of therapy in advanced breast cancer

Advanced breast cancer represents a common clinical problem faced by medical oncologists, internists, surgeons, and radiation oncologists. The medical oncologist or internist is usually the patient's primary physician and is responsible for coordinating the multiple disciplines to optimize the therapeutic management. In the case of locally advanced (stage III) breast cancer, there are far fewer prospective clinical trials on which to base management decisions than are available in the metastatic disease setting. The primary cancer care physician's responsibility is particularly great for coordination of the multidisciplinary approach and integration of medical oncology, radiation oncology, and surgical treatment modalities, however. In the case of metastatic breast cancer, an understanding of the importance of certain clinical factors (that is, hormonal receptors, performance score, disease-free interval, sites and extent of metastasis, and tempo of disease) is crucial to the development of the therapeutic plan in the individual patient. Although entry on a state-of-the-art clinical trial is the appropriate goal, this is not always possible, and an understanding of therapeutic options is essential. Palliation is the key word in the management of metastatic breast cancer, and hormonal therapy is generally the most appropriate course unless the patient is not a hormonal candidate because of sites, extent, or tempo of disease, or because of the known lack of hormonal receptors. Of particular importance is attention to sites of bone metastasis where appropriate radiation therapy and/or surgical intervention can relieve pain or prevent a devastating fracture with resultant loss of mobility and decrease in quality of life.     

Comparison of treatment costs of grade 3/4 adverse events associated with erlotinib or pemetrexed maintenance therapy for patients with advanced non-small-cell lung cancer (NSCLC) in Germany, France, Italy, and Spain

Objective of this indirect economic comparison was to estimate and compare management costs of grade 3/4 adverse events (AEs) reported for first-line erlotinib or pemetrexed maintenance therapy in patients with advanced non-small cell lung cancer (NSCLC). The economic analysis was performed for Germany, France, Italy and Spain.Types and incidences of reported grade 3/4 AEs observed with erlotinib or pemetrexed maintenance therapy were retrieved from two recently published placebo-controlled trials. Country-specific estimates on standard treatment algorithms and incremental medical resource utilization associated with each of the reported grade 3/4 AEs have been obtained from clinical oncologists practicing in the four countries and co-authoring this article. The resource use items were subsequently assigned country-specific tariffs to estimate total per-patients costs associated with the AE profiles of the two compared maintenance regimens. For the economic analysis a customized economic spreadsheet model was employed.Our comparison shows lower total average per-patient AE management costs for erlotinib than for pemetrexed maintenance therapy in all four studied countries. Total estimated cost savings per patient in favour of erlotinib amount to € 121, € 237, € 106, and € 119 for Germany, France, Italy and Spain, respectively. These AE cost savings for erlotinib when compared to pemetrexed represent a decrease by 80%, 71%, 94%, and 82%, respectively. The study also discovered considerable differences in AE management costs across countries which are primarily due to differences in clinician's estimates of hospitalization referral rates.Erlotinib maintenance therapy in patients with advanced NSCLC causes lower AE management costs than pemetrexed maintenance therapy indicating a potentially superior tolerability profile.     

The Royal Australian and New Zealand College of Radiologists (RANZCR) relative value unit workload model,its limitations and the evolution to a safety,quality and performance framework

The study reports on the evolution of the Australian radiologist relative value unit (RVU) model of measuring radiologist reporting workloads in teaching hospital departments, and aims to outline a way forward for the development of a broad national safety, quality and performance framework that enables value mapping, measurement and benchmarking. The Radiology International Benchmarking Project of Queensland Health provided a suitable high‐level national forum where the existing Pitman–Jones RVU model was applied to contemporaneous data, and its shortcomings and potential avenues for future development were analysed. Application of the Pitman–Jones model to Queensland data and also a Victorian benchmark showed that the original recommendation of 40 000 crude RVU per full‐time equivalent consultant radiologist (97–98 baseline level) has risen only moderately, to now lie around 45 000 crude RVU/full‐time equivalent. Notwithstanding this, the model has a number of weaknesses and is becoming outdated, as it cannot capture newer time‐consuming examinations particularly in CT. A significant re‐evaluation of the value of medical imaging is required, and is now occurring. We must rethink how we measure, benchmark, display and continually improve medical imaging safety, quality and performance, throughout the imaging care cycle and beyond. It will be necessary to ensure alignment with patient needs, as well as clinical and organisational objectives. Clear recommendations for the development of an updated national reporting workload RVU system are available, and an opportunity now exists for developing a much broader national model. A more sophisticated and balanced multidimensional safety, quality and performance framework that enables measurement and benchmarking of all important elements of health‐care service is needed.     

Delivering affordable cancer care in high-income countries

The burden of cancer is growing, and the disease is becoming a major economic expenditure for all developed countries. In 2008, the worldwide cost of cancer due to premature death and disability (not including direct medical costs) was estimated to be US$895 billion. This is not simply due to an increase in absolute numbers, but also the rate of increase of expenditure on cancer. What are the drivers and solutions to the so-called cancer-cost curve in developed countries? How are we going to afford to deliver high quality and equitable care? Here, expert opinion from health-care professionals, policy makers, and cancer survivors has been gathered to address the barriers and solutions to delivering affordable cancer care. Although many of the drivers and themes are specific to a particular field-eg, the huge development costs for cancer medicines-there is strong concordance running through each contribution. Several drivers of cost, such as over-use, rapid expansion, and shortening life cycles of cancer technologies (such as medicines and imaging modalities), and the lack of suitable clinical research and integrated health economic studies, have converged with more defensive medical practice, a less informed regulatory system, a lack of evidence-based sociopolitical debate, and a declining degree of fairness for all patients with cancer. Urgent solutions range from re-engineering of the macroeconomic basis of cancer costs (eg, value-based approaches to bend the cost curve and allow cost-saving technologies), greater education of policy makers, and an informed and transparent regulatory system. A radical shift in cancer policy is also required. Political toleration of unfairness in access to affordable cancer treatment is unacceptable. The cancer profession and industry should take responsibility and not accept a substandard evidence base and an ethos of very small benefit at whatever cost; rather, we need delivery of fair prices and real value from new technologies.     

Evidence-Based Decision Making as a Tool for Continuous Professional Development in the Medical Radiation Technologies

All components of contemporary health care practice must be supported by the best available evidence in order to maximize the potential for successful patient care. As in other disciplines, researched-based evidence is a major contributor to the development of contemporary clinical practice and decision making in the medical radiation technologies.However, in recent years a rapid proliferation of clinical studies and journal publications combined with a growing complexity of diagnostic imaging methods has made it difficult for practicing medical radiation technologists (MRT's) to remain current with the relevant clinical research. Because we rely on this clinical research evidence to determine the efficacy and applicability of new diagnostic tests and treatments, it is essential that we possess the skills for the effective procurement and interpretation of the scientific literature. For MRT's, barriers to this task may include lack of training in: defining good clinical questions, the optimal use the bibliographic databases and search engines used in accessing scientific research literature, and the appraisal and integration of acquired research evidence.Evidence-based decision making (EBDM) is a systematic process that enables the “conscientious, explicit, and judicious use of the current best evidence in making health care decisions.” 1 The development of this approach is derived in large part by the need to manage information overload. Such information is essential to the management of skyrocketing health care costs, ensuring the delivery of best diagnosis and treatment. When combined with clinical skills and judgments, patient values and expectations, the EBDM approach serves to maximize the potential for achieving successful patient care outcomes. Specifically, the implementation of EBDM has been shown to: close the gap between knowledge and practice, decrease variability in practice, and increase the use of best research evidence in practice thereby improving the level of clinical care provided by health care professionals. In this directed study article, we define the EBDM process as it pertains to medical radiation technologies.     

胃癌切除术后并发症的术前预测因素分析

风险管理日益成为一个重要的医疗问题。胃大部切除加淋巴结清扫仍是胃癌的主要治疗方法,但术后并发症影响患者的生活质量、辅助治疗的耐受性及预后。通过术前各项指标的参数确定患者出现术后并发症的风险,可以为患者提供精确的知情同意和最佳的围手术期处理,且可以将医疗成本降至最低。在此背景下,许多研究已经确定了预测术后并发症的因素,包括体质、营养、临床资料、器官功能和高凝等指标。本文就胃癌切除术后并发症的术前预测因素及其未来发展进行展望。