The impact of diagnosis and treatment of rectal cancer on paid and unpaid labor

PURPOSE

This study was designed to describe the consequences of diagnosis and treatment of rectal cancer for paid and unpaid labor over time and to identify sociodemographic-related factors, treatment-related factors, and quality of life-related factors associated with paid and unpaid labor.

METHODS

Data were assessed prospectively in two samples of patients with primary rectal cancer, participating in a multicenter clinical trial, who were randomized to receive surgery with or without 5 x 5-Gy preoperative radiotherapy. For paid labor, 292 patients who indicated paid labor before treatment filled out quality of life questionnaires, which included questions on paid labor at 3, 6, 12, 18, and 24 months after surgery. For unpaid labor, another sample of 92 patients also filled out the Health and Labor questionnaire, which included questions on unpaid labor, before treatment, and at 3 and 12 months after treatment.

RESULTS

From 3 to 18 months after surgery, paid labor resumption increased from 19 to 63 percent (P < 0.001). At 24 months after surgery, paid labor resumption was 61 percent. In a multivariate analysis, age older than 55 years (P <or= 0.001), lower education level (P <or= 0.003), shorter time since surgery (P < 0.001), preoperative radiotherapy (P = 0.02), lower valuation of overall health (P < 0.01), more physical symptom distress (P < 0.001), and more limitations in daily activities (P < 0.001) were all associated with less or later resumption of paid labor. The average amount of unpaid labor increased from 17.3 hours per week at 3 months to 21 hours per week at 12 months after surgery. In a multivariate analysis, only shorter time since surgery (P = 0.03) and male gender (P < 0.001) were related to less unpaid labor.

CONCLUSIONS

Diagnosis and treatment of rectal cancer affect paid and unpaid labor. The impact on paid labor is most pronounced. Multiple other sociodemographic and quality of life-related variables also were associated with paid labor. Patient information and decision making on preoperative radiotherapy should include the effects on paid labor, and interventions focused on promoting paid labor participation in patients with rectal cancer should be tailored to the specific characteristics and needs of those patients.

Self-reports of health-care utilization: Diary or questionnaire?

Objectives:The feasibility and convergent validity of a cost diary and a cost questionnaire was investigated.

Methods:Data were obtained as part of a cost-utility analysis alongside a multicenter clinical trial in patients with resectable rectal cancer. A sample of 107 patients from 30 hospitals was asked to keep a weekly diary during the first 3 months after surgery, and a monthly diary from 3 to 12 months after surgery. A second sample of seventy-two patients from twenty-eight hospitals in the trial received a questionnaire at 3, 6, and 12 months after surgery, referring to the previous 3 or 6 months. Format and items of the questions were similar and included a wide range of medical and nonmedical items and costs after hospitalization for surgery.

Results:Small differences were found with respect to nonresponse (range, 79 to 86 percent) and missing questions (range, 1 to 6 percent between the diary and questionnaire). For most estimates of volumes of care and of costs, the diary and questionnaire did not differ significantly. Total 3-month nonhospital costs were €1,860, €1,280, and €1,050 in the diary sample and €1,860, €1,090, and €840 in the questionnaire sample at 3, 6, and 12 months after surgery, respectively (p=.50). However, with respect to open questions, the diary sample tended to report significantly more care.

Conclusions:For the assessment of health-care utilization in economic evaluations alongside clinical trials, a cost questionnaire with structured closed questions may replace a cost diary for recall periods up to 6 months.

Results of the Dutch National study of the palliative effect of irradiation using two different treatment schemes for non-small-cell lung cancer

PURPOSE

A national multicenter randomized study compared the efficacy of 2 x 8 Gy versus our standard 10 x 3 Gy in patients with inoperable stage IIIA/B (with an Eastern Cooperative Oncology Group score of 3 to 4 and/or substantial weight loss) and stage IV non-small-cell lung cancer.

PATIENTS AND METHODS

Between January 1999 and June 2002, 297 patients were eligible and randomized to receive either 10 x 3 Gy or 2 x 8 Gy by external-beam irradiation. The primary end point was a patient-assessed score of treatment effect on seven thoracic symptoms using an adapted Rotterdam Symptom Checklist. Study sample size was determined based on an average total symptom score difference of more than one point over the initial 39 weeks post-treatment. The time course of symptom scores were also evaluated, and other secondary end points were toxicity and survival.

RESULTS

Both treatment arms were equally effective, as the average total symptom score over the initial 39 weeks did not differ. However, the pattern in time of these scores differed significantly (P < .001). Palliation in the 10 x 3-Gy arm was more prolonged (until week 22) with less worsening symptoms than in 2 x 8-Gy. Survival in the 10 x 3-Gy arm was significantly (P = .03) better than in the 2 x 8-Gy arm with 1-year survival of 19.6% (95%CI, 14.1% to 27.3%) v 10.9% (95%CI, 6.9% to 17.3%).

CONCLUSION

The 10 x 3-Gy radiotherapy schedule is preferred over the 2 x 8-Gy schedule for palliative treatment, as it improves survival and results in a longer duration of the palliative response.

Cost-utility and cost-effectiveness analyses of a long-term, high-intensity exercise program compared with conventional physical therapy in patients with rheumatoid arthritis

OBJECTIVE

To estimate the cost utility and cost effectiveness of long-term, high-intensity exercise classes compared with usual care in rheumatoid arthritis (RA) patients.

METHODS

RA patients (n = 300) were randomly assigned to either exercise classes or UC; followup lasted for 2 years. Outcome measures were quality-adjusted life years (QALYs) according to the EuroQol (EQ-5D), Short Form 6D (SF-6D), and a transformed visual analog scale (VAS) rating personal health; functional ability according to the Health Assessment Questionnaire (HAQ) and McMaster Toronto Arthritis Patient Preference Interview (MACTAR); and societal costs.

RESULTS

QALYs in both randomization groups were similar according to the EQ-5D and SF-6D, but were in favor of usual care according to the VAS (annual difference 0.037 QALY; 95% confidence interval [95% CI] 0.002, 0.069). Functional ability was similar according to the HAQ, but in favor of the exercise classes according to the MACTAR (annual difference 2.9 QALY; 95% CI 0.9, 4.9). Annual medical costs of the exercise program were estimated at 780 per participating patient (1 approximately $1.05). The increase per patient in total medical costs of physical therapy was estimated at 430 (95% CI 318, 577), and the increase in total societal costs at 602 (95% CI -490, 1,664). For societal willingness-to-pay equal to 50,000 per QALY, usual care had better cost utility than exercise classes, and significantly so according to the VAS.

CONCLUSION

From a societal perspective and without taking possible preventive health effects into account, long-term, high-intensity exercise classes provide insufficient improvement in the valuation of health to justify the additional costs.

Clinical nature and prognosis of locally recurrent rectal cancer after total mesorectal excision with or without preoperative radiotherapy

PURPOSE

To document the clinical nature and prognosis of locally recurrent rectal cancer after total mesorectal excision (TME) with or without 5 x 5 Gy preoperative radiotherapy (PRT) and to identify patient-, disease-, and treatment-related factors associated with differences in prognosis after local recurrence.

PATIENTS AND METHODS

For 96 Dutch patients with a local recurrence who participated in a multicenter randomized clinical trial, data on treatments and follow-up were gathered from surgeons and radiation and medical oncologists. Twenty-three patients (24%) had previously been treated with PRT plus TME, and 73 patients (76%) had been treated with TME alone. Eighty-one patients (84%) were followed until death; median follow-up time of the alive patients after local recurrence was 21 months (range, 5 to 48 months).

RESULTS

Survival after local recurrence in the PRT + TME group was significantly shorter than in the TME group (median survival, 6.1 v 15.9 months; hazard ratio for death, 2.1; P =.008). Patients with a local recurrence in the PRT + TME group had distant metastases more often (74% v 40%; P =.004), underwent surgical resection of local recurrence less often (17% v 35%; P =.11), and received radiotherapy for local recurrence at a total dose >/= 45 Gy less often (4% v 42%; P =.001) than patients without PRT. In a multivariate analysis, the difference in survival after local recurrence between randomization groups was no longer statistically significant (hazard ratio for death of PRT, 1.53; P =.16).

CONCLUSION

The clinical nature and prognosis of patients with locally recurrent rectal cancer has changed since the introduction of PRT. The majority of patients who present with a local recurrence after previous PRT have simultaneous distant metastases, and median survival has decreased to 6 months.

Cost measurement in economic evaluations of health care: whom to ask?

PURPOSES

The purposes of this study were 1) to investigate the feasibility of using providers' administrative systems for the assessment of healthcare utilization in economic evaluations performed alongside multicenter studies, 2) to assess the convergent validity of patients' and providers' reports of care, and 3) to investigate whether differences between providers' and patients' reports are related to age, gender, health, recall period, and volumes of care.

METHODS

Data were obtained as part of a cost-utility analysis alongside a multicenter clinical trial in patients with rectal cancer. For a sample of 179 patients from 49 hospitals, data on hospitalizations, outpatient visits, medications, and care products during the first year after treatment were obtained from the patients by questionnaire or diary. For all patients, hospitals were contacted for information on hospitalizations and outpatient visits. For a subsample of 94 patients, 86 pharmacists and 10 suppliers of stoma care products were contacted for information on medications and care products.

RESULTS

Response by providers of care was high, ranging from 84% to 100%. With respect to hospital days and outpatient visits, we found no significant differences between patients' and providers' reports. For medications and care products, agreement was lower, with providers reporting up to 2 times more product types and costs than patients. Providers failed to report 20% to 25% of all products, whereas patients failed to report 50% to 60% of all products.

CONCLUSIONS

Patients' reports seem as valid as providers' reports for hospital days and outpatient visits. For medications and care products, we recommend the use of reports from providers of care, whenever feasible, because they much less underestimate volumes and costs than patients.

Effects of transfusion with red cells filtered to remove leucocytes: randomised controlled trial in patients undergoing major surgery

OBJECTIVE

To compare postoperative complications in patients undergoing major surgery who received non-filtered or filtered red blood cell transfusions.

DESIGN

Prospective, randomised, double blinded trial.

SETTING

19 hospitals throughout the Netherlands (three university; 10 clinical; six general).

PARTICIPANTS

1051 evaluable patients: 79 patients with ruptured aneurysm, 412 patients undergoing elective surgery for aneurysm, and 560 undergoing gastrointestinal surgery.

INTERVENTIONS

The non-filtered products had the buffy coat removed and were plasma reduced. The filtered products had the buffy coat removed, were plasma reduced, and filtered before storage to remove leucocytes.

MAIN OUTCOME MEASURES

Mortality and duration of stay in intensive care. Secondary end points were occurrence of multi-organ failure, infections, and length of hospital stay.

RESULTS

No significant differences were found in mortality (odds ratio for filtered v non-filtered 0.80, 95% confidence interval 0.53 to 1.21) and in mean stay in intensive care (- 0.4 day, - 1.6 to 0.6 day). In the filtered group the mean length of hospital stay was 2.4 days shorter (- 4.8 to 0.0 day; P = 0.050) and the incidence of multi-organ failure was 30% lower (odds ratio 0.70, 0.49 to 1.00; P = 0.050). There were no differences in rates of infection (0.98, 0.73 to 1.32).

CONCLUSION

The use of filtered transfusions in some types of major surgery may reduce the length of hospital stay and the incidence of postoperative multi-organ failure.

The heart-allocation simulation model: a tool for comparison of transplantation allocation policies1

BACKGROUND

Numerous studies have investigated prognostic factors for the survival of transplant candidates waiting for a donor organ, but little is known about the impact of allocation policies on waiting list outcome. Simulation models would allow a comparison of different policies for allocating donor hearts on pretransplant outcome.

METHODS

A model was built for the Eurotransplant waiting list for heart transplantation. Survival and delisting distributions were estimated from the Eurotransplant transplant candidate inflow between 1995 and 2000 (n=7,142). Other characteristics were obtained directly from the transplant candidate inflow of 1999 and 2000 (n=2,097) and the donor organs of 1998 and 1999 (n=1,520). Overall and subgroup waiting list mortality were estimated for allocation policies differing by ABO blood group, border, and clinical profile rules.

RESULTS

The model estimated that international organ exchange reduces waiting list mortality in the different countries by 1.9% to 12.4%. An allocation policy incorporating the initial clinical profile of the transplant candidates further reduced waiting list mortality by 1.7%. Changing ABO rules toward identical matching yielded a slightly more equitable survival for the different groups, without an overall effect on mortality. The best possible allocation policy is the policy where organs are allocated to patients that are at highest risk of dying, and withholding organs from patients that would eventually delist because of improvement.

CONCLUSIONS

Patients benefit from international organ exchange and by a heart allocation scheme based on clinical profiles. Timely delisting of patients who are-temporarily-too well for transplantation is the best waiting list policy.

The area under an ROC curve with limited information

The area under the receiver operating characteristic (ROC) curve of a diagnostic test can be used as a summary measure for its discriminative ability. If only a single point of an ROC curve is available, then the entire form of the ROC curve is unknown and the area under it cannot be calculated. Assuming that the unknown ROC curve is either monotone or concave, lower and upper bounds are derived for the area. From these bounds, the minmax approximations are obtained. Compared to only assuming monotonicity, assuming that the unknown ROC curve is concave renders a higher minmax approximation for the area under it, with tighter bounds.

Single- versus multiple-fraction radiotherapy in patients with painful bone metastases: cost-utility analysis based on a randomized trial

BACKGROUND

Radiotherapy is an effective palliative treatment for cancer patients with painful bone metastases. Although single- and multiple-fraction radiotherapy are thought to provide equal palliation, which treatment schedule provides better value for the money is unknown. We compared quality-adjusted life expectancy (the overall valuation of the health of the patients) and societal costs for patients receiving either single- or multiple-fraction radiotherapy.

METHODS

A societal cost-utility analysis was performed on a Dutch randomized, controlled trial of 1157 patients with painful bone metastases that compared pain responses and quality of life from a single-fraction treatment schedule of 8 Gy with a treatment schedule of six fractions of 4 Gy each. The societal values of life expectancies were assessed with the EuroQol classification system (EQ-5D) questionnaire. A subset of 166 patients also answered additional questionnaires to estimate nonradiotherapy and nonmedical costs. Statistical tests were two-sided.

RESULTS

Comparing the single- and multiple-fraction radiotherapy schedules, no differences were found in life expectancy (43.0 versus 40.4 weeks, P =.20) or quality-adjusted life expectancy (17.7 versus 16.0 weeks, P =.21). The estimated cost of radiotherapy, including retreatments and nonmedical costs, was statistically significantly lower for the single-fraction schedule than for the multiple-fraction schedule ($2438 versus $3311, difference = $873, 95% confidence interval [CI] on the difference = $449 to $1297; P<.001). The estimated difference in total societal costs was larger, also in favor of the single-fraction schedule, but it was not statistically significant ($4700 versus $6453, difference = $1753, 95% CI on the difference = -$99 to $3604; P =.06). For willingness-to-pay between $5000 and $40 000 per quality-adjusted life year, the single-fraction schedule was statistically significantly more cost-effective than the multiple-fraction schedule (P< or =.05).

CONCLUSIONS

Compared with multiple-fraction radiotherapy, single-fraction radiotherapy provides equal palliation and quality of life and has lower medical and societal costs, at least in The Netherlands. Therefore, single-fraction radiotherapy should be considered as the palliative treatment of choice for cancer patients with painful bone metastases.

Routine duplex surveillance does not improve the outcome after carotid endarterectomy: a decision and cost utility analysis

BACKGROUND

Doppler ultrasound (duplex) tests are commonly applied after carotid endarterectomy to detect possible recurrent stenosis. The appropriate frequency and the benefits are unknown. We investigated the costs and effects of various follow-up strategies to determine the optimal strategy after carotid endarterectomy.

METHODS

Using decision-analytic methods, a Monte Carlo Markov model was constructed. Probabilities and costs were obtained by systematic literature review. From empirical data regarding restenosis, a disease model was constructed to test the effect of various follow-up strategies using duplex testing and angiography. Main outcome measures were quality-adjusted life-years (QALYs), probability of stroke, and costs (for both the Dutch and the American situation).

RESULTS

The average quality-adjusted life expectancy for a 66-year-old patient was 6.31 years for the symptom-guided strategy (with duplex scanning only being performed in case of symptoms of cerebral ischemia). The mean lifetime costs for this strategy were $5 600 for the US and 4 600 Euro for the Netherlands. The cumulative probability of stroke was 13%. Yearly routine duplex tests up to 5 years after operation resulted in similar QALYs and a similar probability of stroke, but higher costs ($7 300 for the US and 5 600 Euro for The Netherlands situation). No other strategy, including routine duplex surveillance, increased QALYs. When MR instead of conventional angiography was used as confirmatory test, no improvement was observed either.

CONCLUSIONS

Routine duplex surveillance does not result in an increase in quality-adjusted life expectancy, but it does increase costs. After successful carotid endarterectomy, a symptom-guided follow-up is an appropriate approach.