The financial benefits of acute inpatient palliative medicine: an inter-institutional comparative analysis by all patient refined-diagnosis related group and case mix index

Financial comparisons of acute care hospital services are possible using the Centers for Medicare & Medicaid Services case mix index (CMI) and All Patient Refined-Diagnosis Related Group (APR-DRG) data. We compared The Cleveland Clinic's Inpatient Palliative Medicine (CCIPM) acute care unit's CMI and APR-DRG data with national and peer institution data. Total mean charges per admission to the CCIPM unit were 7,800 dollars lower than at other peer institutions despite an equivalent severity of illness and longer length of stay and higher mortality in the CCIPM unit. The lower charges were due primarily to lower laboratory and pharmaceutical charges.We conclude that an acute inpatient palliative medicine unit operating within a comprehensive integrated palliative medicine program is cost-effective in providing specialized care for people with advanced disease.     

Inpatient burden of gastrointestinal stromal tumors in the United States

The purpose of this study was to determine the inpatient burden among patients with gastrointestinal stromal tumors (GISTs). The study assessed hospitalization rates of GISTs and compared hospital characteristics among patients with and without GISTs. Further, predictors of total charges and mortality among patients with GISTs were identified.The 2009 Healthcare Utilization Project Nationwide Inpatient Sample (HCUP-NIS) database was analyzed for this study. Inpatient burden among patients with GISTs (cases) was compared to that among patients without GISTs or any diagnosis of cancer (controls). Linear regression was used to determine the factors predicting total charges, and logistic regression was used to determine predictors of mortality. Analyses were performed using SAS version 9.2.In 2009, there were 14,562 hospitalizations among patients with GISTs at a rate of 44/100,000 admissions. Hospitalization rates among patients with GISTs varied by patient-, hospital-, and discharge-level characteristics. Patients with GISTs had longer length of stay (LOS), total charges, and mortality rate as compared to the control group. Total charges for hospitalizations among patients with GISTs varied by household income, hospital location and region, LOS, and number of diagnoses on record, respectively. When examining the predictors of mortality, household income, hospital region, and number of diagnoses on record emerged significant.By examining the inpatient burden among patients with GISTs, this study fills a critical gap in this area of research. Future studies could merge medical services claims data with cancer registry data to study in-depth the humanistic and economic burden associated with GISTs.Key Words: Gastrointestinal stromal tumors, inpatient, charges, mortality     

Study of hormone refractory prostate cancer: hospital care and palliative care resource use at a VA medical center

Palliative care plays a central role in the management of hormone refractory prostate cancer patients (HRPC), yet little is known about palliative care resource use. Computerized medical records of a retrospective cohort of 89 consecutive HRPC patients seen at a VA medical center from 1994 to 1999 were reviewed for hospital and palliative care resource use in the last 6 months of life. There were 51 Caucasian and 38 African American patients; 95% of patients were admitted to the hospital for symptom management (median of 2 admissions); 98% visited clinics (median 19 visits); 35% went to the emergency room (median of 1 visit); 60% died in the hospital (median length of last hospitalization of 22 days); 49% received palliative radiation; 52% used rehabilitation; 57% received blood transfusion (median 2 units). Thirty-five patients (40%) received hospice care (median stay 35 days). The most frequently prescribed medications included opioids (90%), laxatives (89%), H2-blockers (57%), antiemetics (55%), diuretics (49%), and corticosteroids (43%). The prevalence of patients receiving opioids, as well as the dose of opioids increased over time. There was no difference in categories of palliative care resource use or survival by race. The median survival for all patients was 13 months. The results begin to highlight the extent of care and resources needed by patients with end-stage HRPC. This information will be of importance in planning palliative care for patients with HRPC and in designing future prospective studies.     

Patterns of death among patients treated at a Department of Medical Oncology in Spain

Introduction. Despite significant advances in the palliative care of cancer patients with terminal disease, a considerable proportion of them still die at hospital. The causes of this fact are multiple including sociocultural, familial, and sanitary reasons. Material and methods. A retrospective study was performed on the place and cause of death among patients treated at a Department of Medical Oncology in two time periods (10/1996–10/1997 and 2001) in order to assess the actual situation and its evolution through the last years. Our department assumes both the active treatment and the palliative care of patients assigned to its area. In 2001, 1,254 new cases were referred and 1,006 hospital admissions were recorded, with a median stay of 11 days. In the same period, 424 patients died. Results. Of them, 250 (59%) deaths occurred at hospital (25% of the department discharges). The most common neoplasms were lung (24%), colorectal (14%), and breast (9%). The median hospital stay was 8 days (range, 1–60). The causes of death were cancer progression (79%), intercurrent diseases (11%), and complications during active treatment (10%). In comparison with the former group, among patients dying at home there was a greater relative percentage of women, diagnoses of breast cancer, lymphoma and multiple neoplasms, elderly patients, and deaths due to tumor progression. Conclusions. Nearly 60% of cancer patients who die in our environment do it at hospital. Of them, 20% do not die specifically of tumor progression. The pattern of deaths at home is somewhat different. Sanitary resources should be adapted to the particular care features of each department, favoring the development and coordination of palliative care units, both hospital-based and home care teams.     

Partial nephrectomy in frail patients: Benefits of robot-assisted surgery

BackgroundTo compare the effect of robot-assisted (RAPN) vs. open (OPN) partial nephrectomy on short-term postoperative outcomes and total hospital charges in frail patients with non-metastatic renal cell carcinoma (RCC).MethodsWithin the National Inpatient Sample database we identified 2745 RCC patients treated with either RAPN or OPN between 2008 and 2015, who met the Johns Hopkins Adjusted Clinical Groups frailty-defining indicator criteria. We examined the rates of RAPN vs. OPN over time. Moreover, we compared the effect of RAPN vs. OPN on short-term postoperative outcomes and total hospital charges. Time trends and multivariable logistic, Poisson and linear regression models were applied.ResultsOverall, 1109 (40.4%) frail patients were treated with RAPN. Rates of RAPN increased over time, from 16.3% to 54.7% (p < 0.001). Frail RAPN patients exhibited lower rates (all p < 0.001) of overall complications (35.3 vs. 48.3%), major complications (12.4 vs. 20.4%), blood transfusions (8.0 vs. 13.5%), non-home-based discharge (9.6 vs. 15.2%), shorter length of stay (3 vs. 4 days), but higher total hospital charges ($50,060 vs. $45,699). Moreover, RAPN independently predicted (all p < 0.001) lower risk of overall complications (OR: 0.58), major complications (OR: 0.55), blood transfusions (OR: 0.60) and non-home-based discharge (OR: 0.51), as well as shorter LOS (RR: 0.77) but also higher total hospital charges (RR: +$7682), relative to OPN.ConclusionsIn frail patients, RAPN is associated with lower rates of short-term postoperative complications, blood transfusions and non-home-based discharge, as well as with shorter LOS than OPN. However, RAPN use also results in higher total hospital charges.     

In-hospital complications of autologous hematopoietic stem cell transplantation for lymphoid malignancies: clinical and economic outcomes from the Nationwide Inpatient Sample

BACKGROUND: Autologous hematopoietic stem cell transplantation (auto HSCT) is standard of care therapy for multiple myeloma and Hodgkin and non-Hodgkin lymphomas in front-line and salvage settings, respectively. Complications remain common, but population-based estimates of their frequency and relative contribution to cost are not available. METHODS: A retrospective cohort comprised of 8891 patients with multiple myeloma and lymphoma admitted to US hospitals for auto HSCT over a 2-year period (2000-2001) was extracted from the Nationwide Inpatient Sample (NIS). Patient characteristics, vital status, and total hospital charges were obtained directly from the NIS. Transplant characteristics and outcomes were identified by ICD-9-CM codes. Mean hospital charges were examined by outcome and transformed into cost by using Medicare cost-to-charge ratios. Factors associated with hospital cost, length of stay, and in-hospital mortality were explored by using multivariate regression. RESULTS: The mean hospital cost for auto HSCT during this period was $51,312. Significant complications were documented for >50% of admissions. Infectious complications (~60%) and stomatitis (~40%) were the most frequent, and both were associated with increased hospital costs (range, $15,000 to $50,000). In-hospital mortality was rare (<5%) but was associated with markedly increased cost when it occurred. Pretransplant conditioning with total body irradiation was strongly associated with infectious complications, higher cost, and death. CONCLUSIONS: Adverse events are both common and costly after auto HSCT. Strategies to minimize complications could significantly reduce not only morbidity and mortality but also the cost of the procedure. Administrative data can be profitably exploited to investigate outcomes in this population.     

Aggressiveness of care in a prospective cohort of patients with advanced NSCLC

BACKGROUND: Optimal end of life care of patients with terminal cancer is poorly understood. In this study, the aggressiveness of care is described in a cohort of patients with newly diagnosed advanced nonsmall-cell lung cancer (NSCLC). METHODS: Patients within 8 weeks of diagnosis of stage IIIb (with effusions) or IV NSCLC were enrolled in a study to examine the feasibility of involving palliative care services early in the provision of cancer care. Participants received standard oncology treatment and integrated palliative care. All patients were followed prospectively to assess anticancer therapy usage, hospital admissions, hospice utilization, and location of death. RESULTS: At the time of analysis, 40/46 (87%) of enrolled patients had died, with a median length of follow-up of 29.3 months. Aggressive care measures in the final month of life included rates of anticancer therapy (40%), emergency department visits (48%), and hospital admissions (50%). Sixty-five percent of patients received hospice care before death, with a median length of stay of 16 days. Patients with heightened baseline anxiety and mood symptoms were more likely to receive anticancer therapy at the end of life compared with those without such symptoms. CONCLUSIONS: This study demonstrates the frequent use of aggressive measures at the end of life among patients with advanced NSCLC in a tertiary care center, as shown by the number of patients receiving anticancer therapy within 30 days of death and brief utilization of hospice services. Further research is needed to identify predictors of aggressive care and to develop interventions enhancing decision-making at the end of life.     

Craniotomy for the resection of metastatic brain tumors in the U.S., 1988-2000: decreasing mortality and the effect of provider caseload

BACKGROUND: To assist in selecting treatment for patients with brain metastases, the current study assessed the risk of adverse outcomes after contemporary resection of metastatic brain tumors in relation to patient, surgeon, and hospital characteristics, with particular attention to the volume of care and trends in outcomes. METHODS: A retrospective cohort study of 13,685 admissions from the Nationwide Inpatient Sample between 1988-2000 was performed. Multivariate logistic, ordinal, and loglinear regression were used with endpoints of mortality, discharge disposition, length of stay, and total hospital charges. RESULTS: The overall in-hospital mortality rate was 3.1% and an additional 16.7% of patients were not discharged directly home. In multivariate analyses, larger-volume centers were found to have lower mortality rates for intracranial metastasis resection (odds ratio [OR], 0.79; 95% confidence interval [95% CI], 0.59-1.03 [P = 0.09]). An adverse discharge disposition also was less likely at higher-volume hospitals (OR, 0.75; 95% CI, 0.65-0.86 [P < 0.001]). For surgeon caseload, mortality was lower with higher-caseload providers (OR, 0.49; 95% CI, 0.30-0.80 [P = 0.004]) and an adverse discharge disposition occurred significantly less frequently (OR, 0.51; 95% CI, 0.40-0.64 [P < 0.001]). The annual number of resections increased by 79% during the study period, from 3900 (1988) to 7000 (2000). In-hospital mortality rates decreased from 4.6% (1988-1990) to 2.3% (1997-2000), a 49% relative decrease. Length of stay was reported to be significantly shorter with higher-volume providers. Hospital charges were not found to be associated significantly with hospital caseload and were found to be significantly lower after surgery that was performed by higher-caseload surgeons. CONCLUSIONS: The results of the current study found that higher-volume hospitals and surgeons provided superior short-term outcomes after resection of intracranial metastasis was performed, with shorter lengths of stay and a trend toward lower charges.     

Outcome of unresected gastric cancer after laparoscopic diagnosis of peritoneal carcinomatosis

BACKGROUND: Most gastric adenocarcinomas in western countries are locally advanced, and these tumours are often associated with metastatic spread at the time of diagnosis. It is controversial whether palliative surgery can improve symptom control in gastric cancer patients with peritoneal carcinomatosis. OBJECTIVE: To determine the need of palliative procedures and survival in patients affected by gastric cancer with peritoneal carcinomatosis managed without resection. Methods and materials After standard preoperative staging, 160 patients were diagnosed with resectable gastric adenocarcinoma. Laparoscopy was performed in 107 patients (66.9%), finding peritoneal spread in 22 of them (21%). Seventeen of these patients were not submitted to any additional surgical procedure. Data regarding postoperative morbidity and mortality, need of endoscopic, percutaneous or surgical procedures to palliate symptoms, hospital stay and survival were collected. The same data were collected for the 6 non-resected patients who were diagnosed with carcinomatosis by laparotomy. RESULTS: In the "laparoscopy alone" group, there were 2 minor complications and no postoperative mortality. Mean postoperative stay was 6 days. Eight patients had to be readmitted to hospital for symptoms derived from tumour progression, and 10 palliative endoscopic procedures were performed. Surgical interventions were not needed in any case. Mean survival was 11.5 months. Patients submitted only to laparotomy presented higher morbidity and mortality rates, with a longer postoperative stay and survival of less than 5 months. CONCLUSIONS: Laparoscopic staging of gastric cancer can help to avoid unnecessary laparotomies. In patients with peritoneal carcinomatosis diagnosed by laparoscopy, nonsurgical treatment has low morbidity and mortality and permits good symptom relief with no shortening of survival.     

Preoperative chemoradiation for patients with pancreatic cancer: toxicity of endobiliary stents.

PURPOSE: A recent multicenter study of preoperative chemoradiation and pancreaticoduodenectomy for localized pancreatic adenocarcinoma suggested that biliary stent-related complications are frequent and severe and may prevent the delivery of all components of multimodality therapy in many patients. The present study was designed to evaluate the rates of hepatic toxicity and biliary stent-related complications and to evaluate the impact of this morbidity on the delivery of preoperative chemoradiation for pancreatic cancer at a tertiary care cancer center. PATIENTS AND METHODS: Preoperative chemoradiation was used in 154 patients with resectable pancreatic adenocarcinoma (142 patients, 92%) or other periampullary tumors (12 patients, 8%). Patients were treated with preoperative fluorouracil (115 patients), paclitaxel (37 patients), or gemcitabine (two patients) plus concurrent rapid-fractionation (30 Gy; 123 patients) or standard-fractionation (50.4 Gy; 31 patients) radiation therapy. The incidences of hepatic toxicity and biliary stent-related complications were evaluated during chemoradiation and the immediate 3- to 4-week postchemoradiation preoperative period. RESULTS: Nonoperative biliary decompression was performed in 101 (66%) of 154 patients (endobiliary stent placement in 77 patients and percutaneous transhepatic catheter placement in 24 patients). Stent-related complications (occlusion or migration) occurred in 15 patients. Inpatient hospitalization for antibiotics and stent exchange was necessary in seven of 15 patients (median hospital stay, 3 days). No patient experienced uncontrolled biliary sepsis, hepatic abscess, or stent-related death. CONCLUSION: Preoperative chemoradiation for pancreatic cancer is associated with low rates of hepatic toxicity and biliary stent-related complications. The need for biliary decompression is not a clinically significant concern in the delivery of preoperative therapy to patients with localized pancreatic cancer.     

Palliative Systemic Therapy Given near the End of Life for Metastatic Non-Small Cell Lung Cancer

Background: The use of chemotherapy near end of life (EOL) for various cancers is increasing and has been shown to be associated with delayed access to palliative care (PC) and increased aggressiveness in EOL care, without any benefit on survival. Methods: This retrospective study included 90 patients with metastatic non-small cell lung cancer (NSCLC) who received at least one line of palliative systemic anticancer therapy (SACT) and died between 1 November 2014, and 31 October 2016, at Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ). Our primary objective was to evaluate the proportion of patients with NSCLC receiving SACT within 30 days of death. Secondary outcomes were to determine the mean and median delays between the administration of the last treatment and death, and to evaluate if there were differences in characteristics and outcomes (including overall survival (OS)) between patients treated or not within 30 days of death. Results: In our cohort, 22% of patients received SACT within 30 days of death. For the entire cohort, the mean delay between the last treatment and death was 94 days, and the median was 57 days. There were no statistically significant differences between the two groups in terms of baseline characteristics. Use of SACT near EOL was associated with decreased access to PC, higher rates of in hospital death, decreased use of medical aid in dying (MAiD), and a shorter median OS (4.0 vs. 9.0 months). Conclusions: In this retrospective cohort of patients with metastatic NSCLC, 22% of patients received SACT within 30 days of death, with a negative impact on access to PC, higher rates of in hospital death, decreased use of MAiD and palliative sedation, and a shorter median OS.     

Cost of care in a randomised trial of early hospital discharge after surgery for breast cancer

The aim of this study was to determine the effect of the reduction of the length of hospital stay after surgery for breast cancer on the rate of care consumption and the cost of care. Patients with operable breast cancer were randomised to a short or long postoperative hospital stay. Data on care consumption were collected for a period of 4 months in diaries administered by patients, and socioeconomic status was evaluated by questionnaires. A cost minimisation analysis using the 'societal' perspective was performed and savings were compared with the savings of hospital charges. The use of professional home care was higher for the short stay group during the first month (7.2 versus 1.3 h, P < 0.0001). The number of out-patient consultations, the intensity of informal home care and patient's expenses did not increase after early discharge. The total cost of care was reduced by US$1320 by introducing the short stay programme (P = 0.0007), but the savings were substantially lower than the savings in hospital charges (US$2680).     

Epidemiology and outcomes of serious influenza-related infections in the cancer population

BACKGROUND: Although patients with cancer generally respond favorably to vaccination, they may not receive annual influenza vaccinations. The current population-based study described the epidemiology and outcomes of potentially preventable, serious influenza-related infections in patients with cancer. METHODS: From the Nationwide Inpatient Sample, the authors created a subsample that included discharges with any International Classification of Diseases, ninth revision, diagnosis code for cancer and principal diagnosis code for influenza, bronchopneumonia, or pneumonia caused by an unspecified organism. From the latter two diagnosis codes, the authors estimated excess cases during the influenza season for each year and stratum, then selected a random sample from fall and winter discharges. Subset analyses included weighted sample means, frequencies, and analysis of variance values. The authors converted charges to costs using cost-to-charge ratios and inflated these to 2003 U.S. dollars. Hospitalization and mortality rates were calculated using 5-year cancer prevalence estimates. RESULTS: The estimated mean annual hospital discharges of patients with cancer with potentially preventable, serious influenza-related infections numbered 16,000. The average length and cost per stay were 6 days and > USD 6300, respectively. Approximately 9% of patients died in the hospital and 31% needed further skilled care. The estimated age-specific rates for hospitalization and death per 100,000 in the prevalent cancer population were 219 and 17.4, respectively, for patients age < 65 years and 623 and 59.4, respectively, for those age > or = 65 years. Hospitalization costs averaged USD 1300 more for patients age < 65 years. CONCLUSIONS: Death from influenza-related infections occurred in an estimated 9% of patients with cancer hospitalized for such. Using recommended vaccination schedules for patients with cancer and their contacts reduced hospitalizations, treatment delays, and deaths in this highly susceptible population.     

Timing of palliative care referral and symptom burden in phase 1 cancer patients

BACKGROUND:

Phase 1 trials offer patients with advanced cancer the opportunity to pursue life‐prolonging cancer treatments. In the current study, the timing of referral and symptom burden between patients referred to palliative care by phase 1 oncologists and those referred by non‐phase 1 oncologists were compared.

METHODS:

All 57 patients with advanced solid tumors who were referred by phase 1 oncologists to the palliative care outpatient clinic at The University of Texas M. D. Anderson Cancer Center (MDACC) between 2007 and 2008 were included. The comparison cohort was comprised of 114 non‐phase 1 patients who were stratified by age, sex, and cancer diagnosis in a 1:2 ratio. Information regarding patient characteristics, Edmonton Symptom Assessment Scale (ESAS), timing of referral, and survival was retrieved.

RESULTS:

Both cohorts had the following matched characteristics: average age of 57 years, with44% of the patients being female and 47% having gastrointestinal cancers. At the time of palliative care consultation, patients referred by phase 1 oncologists were more likely than patients referred by non‐phase 1 oncologists to have a better performance status (Eastern Cooperative Oncology Group 0–1: 61% vs 36% [P = .003). The ESAS was not significantly different with the exception of better well‐being in the phase 1 cohort (mean, 4.5 vs 5.5; P = .03). No difference was found for the duration between registration at MDACC and palliative care consultation (13 months vs 11 months; P = .41) and overall survival from the time of palliative care consultation (5 months vs 4 months; P = .69).

CONCLUSIONS:

Outpatients referred to palliative care by phase 1 oncologists were found to have a better performance status but similar symptom burden compared with patients referred by non‐phase 1 oncologists. Patients with phase 1 involvement did not appear to have delayed palliative care referral compared with non‐phase 1 patients. The results of the current study support the development of a simultaneous care model. Cancer 2010. © 2010 American Cancer Society.     

A clinical scoring system predicts the yield of diagnostic laparoscopy in patients with potentially resectable hepatic colorectal metastases

BACKGROUND: Laparoscopy may identify occult metastatic disease and prevent unnecessary laparotomy in some patients with potentially resectable colorectal liver metastases but is unnecessary in the majority of individuals who undergo resection. The objectives of the current study were to assess the impact of laparoscopy after extensive preoperative imaging and to determine whether a preoperative clinical risk score can identify those patients most likely to benefit from the procedure. METHODS: Between December 1997 and July 1999, 103 consecutive patients with potentially resectable colorectal liver metastases underwent laparoscopy prior to planned laparotomy and partial hepatectomy. Surgical findings, length of hospital stay, and hospital charges were analyzed. Patients were assigned a clinical risk score (CRS) based on five factors related to the primary tumor and the hepatic disease. The likelihood of finding occult unresectable disease and the yield of laparoscopy were analyzed with respect to the CRS. RESULTS: Seventy-seven patients (75%) underwent resection. Laparoscopy identified 14 of 26 patients with unresectable disease, 10 of whom were spared an unnecessary laparotomy. In patients who underwent biopsy only, the laparoscopic identification of unresectable disease shortened the hospital stay (1.2 +/- 0.6 days vs. 5.8 +/- 2.3 days; p = 0.0001) and reduced the total hospital charges by 55% (P = 0.0001). The CRS predicted the likelihood of occult unresectable disease, which was 12% in those with a score < or = 2 but increased to 42% in those with a score > 2 (P = 0.001). If laparoscopy were used only in high risk patients (CRS > 2), 57 laparoscopies would have been avoided and the net savings doubled. CONCLUSIONS: With extensive preoperative imaging, the vast majority of patients with potentially resectable hepatic colorectal metastases do not benefit from laparoscopy. However, in the minority of patients with occult unresectable disease, laparoscopy prevents unnecessary laparotomy and reduces hospital stay and the total hospital charges. The CRS, previously shown to predict survival after hepatic resection, identifies those high risk patients most likely to benefit from laparoscopy and may improve resource utilization.     

外科多专业合作胸壁切除与重建术在乳腺癌侵犯胸壁患者治疗中的地位

目的探讨由切除外科及重建外科医师合作完成的胸壁切除与重建术（CWRR）在乳腺癌侵犯胸壁患者治疗中的地位。方法由切除外科和重建外科合作完成CWRR44例,切除后胸壁软组织缺损35～800cm^2;同时切除骨性胸壁15例,骨性胸壁缺损5～320cm^2。切除后立即重建43例,因伤口原因延迟重建1例。根治切除36例,姑息切除8例。进行以电话及门诊复查为主的随访,随访时间为5．0～285．0个月。结果全组无手术后30d死亡者。CWRR术后,根治性切除患者术后中位生存时间〉36．0个月,1、3、5年生存率分别为71．5％、65．7％和65．7％;姑息性切除患者术后中位生存时间为15．1个月,1、3、5年生存率分别为35．1％、23．4％和7．8％。根治性切除患者的生存率高于姑息性切除患者（P=0．018）。原发乳腺癌患者术后中位生存时间为44．7个月,1、3、5年生存率分别为78．4％、78．4％和39．2％。复发乳腺癌患者术后中位生存时间为36．0个月,1、3、5年生存率均为70．9％。有转移者术后中位生存时间为16．0个月,1、3、5年生存率分别为30．0％、15．0％和0。原发性乳腺癌患者与复发性乳腺癌患者术后生存率差异无统计学意义（P=0．752）,而有转移者术后生存率明显低于原发乳腺癌患者（P=0．003）或复发乳腺癌患者（P=0．018）。结论只有切除外科和重建外科同时参与才能完成符合肿瘤治疗原则的复杂CWRR。在完成乳腺癌全盘治疗计划、全身和局部疾病得到良好控制的前提下,根治性CWRR能改善侵及胸壁乳腺癌患者的生存,适当的姑息性CWRR可改善患者的生活质量。     

Pattern and Outcome of admission to a medical oncology inpatient service

Background. Inpatient medical oncology has not been properly described in many countries including Turkey.Methods. We aimed in this article to describe the admissions to a medical oncology inpatient service within a 2-year period with respect to patient characteristics, their malignancies, and outcome of admission.Results. A total of 5305 cancer patients were seen at our hospital, and 779 (14.7%) were hospitalized. The most common reason for admission was chemotherapy administration (81.2%). The median number of hospitalizations was 1 (range, 1–21). The length of stay was between 1 to 189 days with a median of 4 days. Most of the hospitalizations resulted in discharge; few patients died (77 patients; 9.9% of the hospitalized patients and 4.4% of the hospitalizations).Conclusions. Inpatient care constitutes an important aspect of medical oncology. Given the high rate of hospitalization for chemotherapy administration and the rising cost of inpatient care, it is evident that a shift from inpatient care to outpatient care (day hospital or ambulatory) is urgently needed.     

Place of death and its predictors for local patients registered at a comprehensive cancer center.

PURPOSE: To help with planning of a palliative care program, we reviewed the place of death of patients who were registered at our comprehensive cancer center and explored factors that predicted death in the hospital versus death at home. PATIENTS AND METHODS: A retrospective study was undertaken of local patients who were registered at the University of Texas M.D. Anderson Cancer Center and died during the 1997/1998 fiscal year. Data from the institutional tumor registry and from the State of Texas Bureau of Vital Statistics file were collected and analyzed. The main outcome measures were place of death, patient characteristics associated with place of death, and time from registration at the institution to death. RESULTS: Of 1,793 local patients, 251 (14%) died at M.D. Anderson Cancer Center; the remaining 86% died elsewhere. A total of 617 (34%) died at home, and 929 (52%) died in an acute hospital setting (including M.D. Anderson). A total of 1,040 (58%) died within 2 years of registration. The risk of hospital death versus home death increased for patients with cancer at a hematologic site (odds ratio [OR], 4.4; 95% confidence interval [CI], 2.8 to 6.8) and black ethnicity (OR, 1.9; 95% CI, 1.4 to 2.6) and decreased for patients who paid with Medicare (OR, 0.71; 95% CI, 0.57 to 0.90). CONCLUSION: Most patients died in an acute care hospital setting and within 2 years of registration. Our data show some predictors of hospital death for cancer patients and suggest that better hospital palliative care services and integrated palliative care systems that bridge community and acute hospitals are needed.     

Outcomes of home anti-cancer chemotherapy--estimation of hepatic arterial infusion chemotherapy for patients with multiple liver metastases

A total of 18 patients (13: colon cancer, 5: gastric cancer) with multiple liver metastases (H3) underwent hepatic arterial infusion chemotherapy (HAI) using an implanted arterial port with portable syringe pumps in our outpatient clinic. Clinical perspective: overall response rate was 22.2% (CR: 1 case, PR: 3 cases (1 case: hepatectomy after HAI), NC: 12 cases, PD: 2 cases), however, 7 of 12 cases of NC were long NC (more than 6 months). No major complications with HAI were experienced. Patient Perspective: After HAI in our outpatient clinic, the 50% survival was 341 days, 50% hospital free days were 319 days and home stay rate was 92.9%. Societal Perspective: cost and hospital stay days were significantly reduced. Home anti-cancer chemotherapy using HAI for gastrointestinal cancer patients with multiple liver metastases was safe and efficient from the viewpoint of medical outcomes.