Quality of integrated care for patients with nonsmall cell lung cancer: variations and determinants of care

BACKGROUND: In the current study, the authors focused on determinants influencing the quality of care and variations in the actual quality of integrated care for patients with nonsmall cell lung cancer (NSCLC) to estimate whether there is room for improvement. METHODS: The authors tested the quality of integrated care for 276 NSCLC patients with 14 quality indicators of professional (4 indicators), organizational (3 indicators), and patient-oriented quality (7 indicators). Patient characteristics and actual care data were derived from medical record data, patient-oriented care was derived from patient questionnaires, and professional and hospital characteristics were derived from questionnaires for professionals. The performance measure was the proportion of patients to whom the indicator applied who had positive scores on the indicator. Multilevel logistic regression analysis determined the influence of patient, professional, and hospital characteristics on care. RESULTS: With regard to professional quality, the proportions of patients who underwent fluorodeoxyglucose-positron emission tomography or cervical mediastinoscopy according to the guideline criteria were 88% and 84%, respectively. Only 50% of the biopsies were adequately obtained during mediastinoscopy, and in 3% of the patients with clinical stage III disease (based on the TNM classification) there was a search for brain metastases before the initiation of combination therapy. With regard to organizational quality, the diagnostic route of 79% of the patients was completed within 21 days; 51% of patients began therapy within 35 days and 57% were discussed during multidisciplinary consultation. All but 1 patient-oriented quality indicator scored /=20% with regard to 11 of the 14 indicators. The patient-related determinants "stage of disease," "age," and "comorbidity" were found to influence the indicator scores the most. CONCLUSIONS: The quality of integrated care (especially patient-oriented care) for NSCLC patients needs improvement. Patient characteristics appear to influence performance more than professional or hospital characteristics.     

A gendered users′ perspective on decentralized primary health services in rural Tanzania

Since the 1990s, Tanzania has been implementing health sector reforms including decentralization of primary healthcare services to districts and users. The impact of the reforms on the access, quality and appropriateness of primary healthcare services from the viewpoint of users is, however, not clearly documented. This article draws on a gendered users' perspective to address the question of whether the delivery of gender‐sensitive primary health services has improved after the reforms. The article is based on empirical data collected through a household survey, interviews, focus group discussions, case studies and analysis of secondary data in two rural districts in Tanzania. The analysis shows that the reforms have generated mixed effects: they have contributed to improving the availability of health facilities in some villages but have also reinforced inter‐village inequalities. Men and women hold similar views on the perceived changes and appropriateness to women on a number of services. Gender inequalities are, however, reflected in the significantly low membership of female‐headed households in the community health fund and their inability to pay the user fees and in the fact that women's reproductive and maternal health needs are as yet insufficiently addressed. Although over half of users are satisfied with the services, more women than men are dissatisfied. The reforms appear to have put much emphasis on building health infrastructure and less on quality issues as perceived by users. Copyright © 2013 John Wiley & Sons, Ltd.     

Patient‐reported health outcomes in patients with non‐melanoma skin cancer and actinic keratosis: results from a large‐scale observational study analysing effects of diagnoses and disease progression

Background

Non‐melanoma skin cancer (NMSC) and actinic keratosis (AK) are very common among fair‐skinned individuals. A disease continuum from AK to squamous cell carcinoma (SCC) has been frequently postulated. AK and NMSC may influence quality of life (QL) of patients, and it can be suspected that disease progression entails a QL reduction. The purpose of this study was to document QL in patients with NMSC and AK using the health‐outcome questionnaire EQ‐5D‐5L.

Methods

The study was designed as a non‐interventional, prospective, cross‐sectional study. Patients with AK, SCC, basal cell carcinoma (BCC) or multiple diagnoses were enrolled in this study in 29 dermatological centres across Germany. Patients were asked to complete the EQ‐5D‐5L (compromising EQ Index and EQ VAS), and the dermatologists provided diagnosis, disease history and treatment data.

Results

A total of 1184 patients were enrolled and diagnosed as follows: 73% AK, 49% BCC and 17% SCC. 66% had a single diagnosis, 28% two different diagnoses and 6% three different diagnoses. QL was strongly associated with patients’ diagnosis. Patients with a single AK diagnosis had significantly higher mean EQ VAS (78) than patients with BCC (74), SCC (72), and BCC plus SCC (69), P < 0.050. When the effects of disease progression were calculated, patients with AK plus SCC reported significantly less mean EQ VAS (71) than patients with a single AK diagnosis (78), P < 0.011.

Conclusions

While rarely being imminently life‐threatening, NMSC and AK have an impact on QL as quantified by the EQ‐5D‐5L. This impact is associated with diagnosis (AK vs. NMSC) and clinical progression (AK vs. AK plus SCC). Both lead to a clear decline in QL. This shows that disease progression is perceived and judged as detrimental by patients and that AK and NMSC should be diligently treated to preserve and restore QL.     

The role of CD44 during CD40 ligand-induced dendritic cell clustering and maturation.

The interaction between CD40 on dendritic cells (DC) and its ligand CD154 has been recognized to be an important feature in the maturation of DC. Here, we were interested in the role of CD44 a surface receptor shown to mediate cell-cell adhesion and binding to Hyaluronic acid (HA). Western blot analysis of human DC stimulated for 3-12 h with CD154 revealed the rapid induction of the 85 kDa standard form of CD44 and an increased HA-binding affinity. Time-lapse video-imaging microscopy of human DC co-cultured on CD154-transfected murine fibroblasts showed that the CD44 up-regulation coincided with the rapid induction of homotypic DC clustering, which did not occur on empty vector-transfected fibroblasts. In this system, addition of anti-CD44s mAbs abrogated DC-cluster formation, thereby inhibiting further maturation, as shown by a reduced TNF-alpha production and inhibition of CD154-induced MHC class II up-regulation. However, co-incubation with HA-degrading enzymes induced no changes in the CD154-mediated DC clustering and maturation.     

Achlorhydria and stomach carcinoma

Patients with achlorhydria are suspected to have an increased risk of developing gastric adenocarcinoma. However, in the literature the reported risk varies considerably. In The Netherlands no such data are available. The risk of developing gastric adenocarcinoma was investigated in 129 achlorhydric patients. During a mean observation period of 12.3 yrs gastric adenocarcinoma was diagnosed in six patients. The expected incidence was 1,275, calculated by making use of age, sex and calendar specific incidence and mortality rates of gastric cancer in the Dutch population. The relative risk to develop gastric cancer was 4.7 (95% confidence limits: 1.7-10.2; p less than 0.05). Despite a significantly increased risk, screening of achlorhydric patients for gastric cancer is not advised.