Breast cancer: better care for less cost. Is it possible?

OBJECTIVES: To estimate the potential for cost reduction in the acute care setting and the required investment in the home care setting of implementing an outpatient/early discharge strategy for operable (stages I and II) breast cancer in Canada. METHODS: Data from a community hospital were augmented by expert knowledge and incorporated into the breast cancer submodel of Statistics Canada's Population Health Model. For the estimated 90% of patients for whom this approach was assumed to be appropriate, the resource utilization for outpatient breast-conserving surgery and 2 days of hospitalization for those women undergoing mastectomy was quantified and costed, as were the appropriate home care services. A 5% readmission rate for complications was assumed. Cost per case, total cost burden, investment in home care, savings in acute care, and net savings were calculated. Sensitivity analyses were performed around readmission rates and home care/surgical follow-up costs. All costs were determined in 1995 Canadian dollars. RESULTS: The cost of initial treatment for the 15,399 women diagnosed with stages I and II breast cancer in 1995 in Canada was estimated to be $127.6 million. Hospitalization made up 53% of these costs. Under the outpatient/early discharge strategy, the acute care cost of initial breast cancer management could be reduced by $47.2 million, with an investment in home care of $14.5 million ($453 per patient), resulting in an overall net saving of $33 million. Under this strategy, hospitalization would contribute only 21% to the total care cost. CONCLUSIONS: If Canadian surgeons and healthcare administrators were to work together to put in place processes to support ambulatory breast cancer surgery and if resources were redirected to the provision of home-based post-operative care, there would be potential for a large net healthcare saving and preservation of high-quality patient care.     

Prevalence and disabilities in 4 to 8 year olds with cerebral palsy.

A register of children born between 1970 and 1979 in the South East Thames Regional Health Authority, and diagnosed as having pre-, peri-, and postnatal cerebral palsy, was set up between 1978 and 1981. We report the 527 children born between 1970 and 1974 for whom ascertainment is virtually complete. The estimated prevalence was 2.2 per 1000, with 7.4% multiple births, and 58% boys. Birthweight distribution is as expected, with 35% weighing less than 2500 g at birth. Parental permission for release of detailed medical information was sought, and the clinicians responsible gave us data on the type of cerebral palsy; details of impairments, disabilities, and anticipated future prospects; and an opinion on the probable timing of the cause. There was a high incidence of orthopaedic defects which must represent a considerable use of resources, although the prevalence of hearing and vision defects suggested that some of these may be undetected.     

Clearance of 3H-dopamine from the amniotic fluid in the rhesus monkey

Previous studies have suggested that dopamine is the major catecholamine in the amniotic fluid; however, there are few data available concerning the metabolism of this hormone in the amniotic fluid compartment. With the use of acute 3H-dopamine injection studies into the amniotic sac of pregnant rhesus monkeys, the dopamine half-life was observed to be 29 minutes, the amniotic fluid volume was 113 ml, the metabolic clearance rate was 164 ml/hr, and the calculated production rate was 436 ng/hr. The biphasic pattern of dopamine clearance from this compartment suggests that it is cleared from the amniotic sac by mechanisms similar to those used in the intravascular compartment.     

Technical aspects of multifocal ERG recording

There are a wide range of variables which can influence the quality of the multifocal response. It is possible to place these variables into one of four categories. First, the method of stimulus delivery will determine the field of view, interference levels and the duration of on-state stimulation. Second, data acquisition variables such as electrode type and placement, amplifier specifications and filter bandwidth settings will have a direct impact on waveform shape and on the topographic distribution of signal amplitudes. Third, patient variables such as fixation, pupil dilation and refractive error will also contribute to the multifocal response. Fourth, there are many measurements that can be taken from multifocal recordings. In addition to standard amplitude and implicit time measures (the implicit time measure in the multifocal response is becoming increasingly important particularly in early stages of disease processes), the scalar product measure provides information on waveform shape. The conventional impulse and higher order responses will be different for different modes of stimulation such as Cathode Ray Tube (CRT) and Liquid Crystal Display (LCD) systems and latency shifts will be introduced if not corrected in software. Procedures which could lead to misleading interpretation include artefact rejection, averaging with neighbours and summing of responses. These procedures should be handled with caution. This revised version was published online in July 2006 with corrections to the Cover Date.     

Development and evaluation of a decision aid for patients with stage IV non‐small cell lung cancer

Although guidelines for treating stage IV non‐small cell lung cancer suggest that the patient’s values should be considered in decision‐making, there are no practical tools available to assist them with their decision‐making.

Objective

To develop and evaluate a decision aid that incorporates patient values.

Design and sample

(1) Before/after evaluation with patients referred to a regional cancer centre. (2) Mailed survey of thoracic surgeons and respirologists in Ontario.

Intervention

An audio‐tape guided individuals to review a booklet describing stage IV non‐small cell lung cancer, its impact and possible coping strategies, treatment options, benefits and risks, and examples of the decision‐making of others. Patients then used a worksheet to consider and communicate personal issues involved in the choice, including: personal values using a ‘weigh‐scale’; questions; preferred role in decision‐making; and predisposition.

Measures

(1) Patient questionnaires eliciting knowledge, the decision, decisional conflict and acceptability of the decision aid. (2) Physician questionnaires eliciting attitudes toward the decision aid.

Results

(1) Twenty of 30 patients used the aid in decision‐making. Users thought that the aid was acceptable and significantly improved their knowledge about options and outcomes (P < 0.001), and reduced their decisional conflict (P < 0.001). (2) The majority of the 29 physicians who reviewed the decision aid found it acceptable, were comfortable providing it to patients and said that they were likely to use it.

Conclusion

The decision aid is a useful and acceptable adjunct to personal counselling.

     

Treatment-independent pregnancies after cessation of gonadotropin ovulation induction in women with oligomenorrhea and anovulatory menses

Life-table analysis was performed for the cumulative spontaneous pregnancy rate (CSPR) of 56 patients with oligomenorrhea and anovulatory cycles who had been treated with gonadotropin for ovulation induction between 1963 and 1985. Twenty-seven had at least one spontaneous pregnancy, giving rise to a CSPR of 66.4% (95% confidence limit [CL] 42.4% to 90.4%) at 115 months for the first spontaneous pregnancy, which is significantly lower than the cumulative induced pregnancy rate (CIPR) of 88.6% at 23 months for the first course of gonadotropin therapy (P less than 0.0001). This fertility potential was not affected by the baseline estrogen and follicle-stimulating hormone levels, diagnosis, result of gonadotropin therapy, and age and menstrual pattern during exposure to spontaneous pregnancy by Cox regression analysis. More multiple births occurred in the induced pregnancies than in the spontaneous pregnancies (P = 0.005).     

Metastasizing Leiomyoma of the Uterus

This report describes a patient who underwent a subtotal hysterectomy 6 years ago for fibroids. She re-presented recently with lung metastases and a pelvic mass. Macroscopic appearances at laparotomy suggested a leiomyosarcoma of the uterine stump, but histological appearances suggested the patient was suffering from the rare condition 'metastasizing leiomyoma'. Subsequent response to hormone manipulation supported the latter diagnosis.     

Determinants of altered anxiety after abnormal maternal serum alpha-fetoprotein screening

With maternal serum alpha-fetoprotein testing, large numbers of previously "low-risk" patients are now considered high risk and are offered genetic testing. Anecdotally, these patients have been perceived as more highly anxious than other second-trimester patients referred for genetic testing because of advanced maternal age. Thus we have studied patient demographics, true genetic risks, the perceptions of risk, and state (situational) and trait (constitutional) anxiety for these patients and their partners. Significantly increased state anxiety was noted for mothers as compared with fathers both in the group of women referred for testing because of maternal serum alpha-fetoprotein levels and in those referred due to advanced maternal age. State anxiety was increased in the women referred for maternal serum alpha-fetoprotein levels as compared with women referred for advanced maternal age. True genetic risks were comparable between the groups. Some critics have argued that maternal serum alpha-fetoprotein screening engenders unnecessary anxiety. Our data show that patients undergoing genetic testing due to maternal serum alpha-fetoprotein levels have higher state anxiety than women undergoing testing because of advanced maternal age, but that indication is much less a factor than are partner differences. Therefore, increased anxiety after abnormal maternal serum alpha-fetoprotein testing results cannot be reasonably used as an argument against such testing.     

A normal ultrasound does not obviate the need for amniocentesis in patients with elevated serum alpha-fetoprotein

Elevated levels of maternal serum alpha-fetoprotein (MSAFP) will identify a population at increased risk for specific congenital malformations, which are accurately diagnosed by amniotic fluid AFP and acetylcholinesterase. The risk for spontaneous abortion related to amniocentesis, combined with increasing confidence in the accuracy of ultrasound diagnosis, has caused us to question the need for amniocentesis in the diagnostic workup of pregnancies complicated by elevated levels of AFP in maternal serum. A retrospective study of 257 pregnancies evaluated for elevated serum AFP levels revealed 16 fetal malformations diagnosed by amniotic fluid AFP and acetylcholinesterase. Only 12 of these malformations were diagnosed on the initial ultrasound study. All malformations were diagnosed when ultrasound examination was repeated for increased acetylcholinesterase activity. Earlier gestational age at scanning, smaller defects, and pure technical failure were implicated as causes of misdiagnosis. The rate of fetal malformations identified in this high-risk population (6.23%) and the rate of ultrasound misdiagnosis (1.5% of the population with elevated levels of MSAFP) imply that amniocentesis should still be considered an essential part of the diagnostic workup in these situations.     

The use of gamma glutamyl transferase activity in amniotic fluid in the detection of fetal trisomy 21

The value of using gamma glutamyl transferase (GT) to select amniotic fluids for karyotyping from patients at low risk of chromosome defects is assessed. This paper reports on 16 pregnancies with fetal trisomy 21 and compares these to two previous reports of GT in fetal trisomy 21. The value of GT is contrasted to the value of AFP in selecting liquors for karyotyping.