Is community treatment best? a randomised trial comparing delivery of cancer treatment in the hospital, home and GP surgery

National expert consensus on home-administered oncologic therapies in Spain

The diagnosis and treatment of cancer impose a significant emotional and psychological burden on patients, families, and caregivers. Patients undergo several interventions in a hospital setting, and the increasing number of patients requiring extended care and follow-up is driving the demand for additional clinical resources to address their needs. Hospital at Home (HaH) teams have introduced home-administered oncologic therapies that represent a new model of patient-centered cancer care. This approach can be integrated with traditional models and offers benefits to both patients and healthcare professionals (HCPs). Home-administered treatment programs have been successfully piloted globally, demonstrated as a preferred option for most patients and a safe alternative that could reduce costs and hospital burden. The document aims to establish the minimum recommendations for the home administration of oncologic therapies (ODAH) based on a national expert agreement. The expert panel comprised seven leading members from diverse Spanish societies and three working areas: clinical and healthcare issues, logistical and administrative issues, and economic, social, and legal issues. The recommendations outlined in this article were obtained after a comprehensive literature review and thorough discussions. This document may serve as a basis for the future development of home-administered oncologic therapy programs in Spain. .

Citizens' perspectives on relocating care: a scoping review

BACKGROUND

Healthcare systems around the world are facing large challenges. There are increasing demands and costs while at the same time a diminishing health workforce. Without reform, healthcare systems are unsustainable. Relocating care, for example, from hospitals to sites closer to patients' homes, is expected to make a key contribution to keeping healthcare sustainable. Given the significant impact of this initiative on citizens, we conducted a scoping review to provide insight into the factors that influence citizens' attitudes towards relocating care.

METHOD

A scoping review was conducted. The search was performed in the following databases: Pubmed, Embase, Cinahl, and Scopus. Articles had to include relocating healthcare and citizens' perspectives on this topic and the articles had to be about a European country with a strong primary care system. After applying the inclusion and exclusion criteria, 70 articles remained.

RESULTS

Factors positively influencing citizens' attitudes towards relocating care included: convenience, familiarity, accessibility, patients having more control over their disease, and privacy. Factors influencing negative attitudes included: concerns about the quality of care, familiarity, the lack of physical examination, contact with others, convenience, and privacy. Furthermore, in general, most citizens preferred to relocate care in the studies we found, especially from the hospital to care provided at home.

CONCLUSION

Several factors influencing the attitude of citizens towards relocating care were found. These factors are very important when determining citizens' preferences for the location of their healthcare. The majority of studies in this review reported that citizens are in favour of relocating care. In general citizens' perspectives on relocating care are very often missing in articles. It was significant that very few studies on relocation from the hospital to the general practitioner were identified.

The future of cancer care in the UK-time for a radical and sustainable National Cancer Plan

Cancer affects one in two people in the UK and the incidence is set to increase. The UK National Health Service is facing major workforce deficits and cancer services have struggled to recover after the COVID-19 pandemic, with waiting times for cancer care becoming the worst on record. There are severe and widening disparities across the country and survival rates remain unacceptably poor for many cancers. This is at a time when cancer care has become increasingly complex, specialised, and expensive. The current crisis has deep historic roots, and to be reversed, the scale of the challenge must be acknowledged and a fundamental reset is required. The loss of a dedicated National Cancer Control Plan in England and Wales, poor operationalisation of plans elsewhere in the UK, and the closure of the National Cancer Research Institute have all added to a sense of strategic misdirection. The UK finds itself at a crossroads, where the political decisions of governments, the cancer community, and research funders will determine whether we can, together, achieve equitable, affordable, and high-quality cancer care for patients that is commensurate with our wealth, and position our outcomes among the best in the world. In this Policy Review, we describe the challenges and opportunities that are needed to develop radical, yet sustainable plans, which are comprehensive, evidence-based, integrated, patient-outcome focused, and deliver value for money.

Fit for Duty: Lessons Learned from Outpatient and Homebound Hematopoietic Cell Transplantation to Prepare Family Caregivers for Home-Based Care

In the past decade, the demand for home-based care has been amplified by the Coronavirus disease 2019 pandemic. Home-based care has significant benefits for patients, their families, and healthcare systems, but it relies on the often-invisible workforce of family and friend caregivers who shoulder essential health care responsibilities, frequently with inadequate training and support. Hematopoietic cell transplantation (HCT), a potentially curative but intensive treatment for many patients with blood disorders, is being increasingly offered in home-based care settings and necessitates the involvement of family caregivers for significant patient care responsibilities. However, guidelines for supporting and preparing HCT caregivers to effectively care for their loved ones at home have not yet been established. Here, informed by the literature and our collective experience as clinicians and researchers who care for diverse patients with hematologic malignancies undergoing HCT, we provide considerations and recommendations to better support and prepare family caregivers in home-based HCT and, by extension, family caregivers supporting patients with other serious illnesses at home. We suggest tangible ways to screen family caregivers for distress and care delivery challenges, educate and train them to prepare for their caregiving role, and create an infrastructure of support for family caregivers within this emerging care delivery model.

Community-based Intravenous Treatment and Central Venous Access Devices: A Scoping Review of the Consumer and Caregiver Experience, Information Preferences, and Supportive Care Needs

PURPOSE

Map existing research and describe the consumer/caregiver experience of community-based intravenous treatment, central venous access devices (CVADs), supportive care needs, and information preferences.

DESIGN

Scoping review.

METHODS

Five databases (Joanna Briggs Institute, Cochrane library, Emcare, Embase, and Medline) were searched. Screening and data extraction were performed independently by two reviewers.

FINDINGS

Forty-eight studies were included.

CONCLUSIONS

Although community-based intravenous treatment and CVADs have a significant impact on consumers and caregivers, there is scant research on their supportive care needs and information preferences.

CLINICAL EVIDENCE

Some consumers and caregivers may require additional support while undergoing community-based intravenous treatment.

“It is a Part of Me”: The Experiences of Patients with Cancer Undergoing Home-Based Chemotherapy

Objective

Home-based chemotherapy is widely used and offers advantages in terms of patient-centeredness, hospital capacity, and cost-effectiveness. However, in practice, patients experience difficulties with self-management and handling the elastomeric infuser. In this study, we aimed to explore the experiences of patients undergoing home-based chemotherapy based on patients’ and nurses’ perspectives. Additionally, we aimed to identify patients’ unmet needs.

Methods

A qualitative descriptive study was conducted in a tertiary hospital in South Korea. Ten patients undergoing home-based chemotherapy and ten nurses with experience in home-based chemotherapy participated. Data were collected by using semi-structured individual interviews and analyzed by using inductive content analysis.

Results

Four main categories were identified based on the interviews: (1) ambivalence regarding comfort vs. enduring the discomfort, (2) acceptance of the discomfort as a part of them, (3) the need for more precise, numerical measurements, and (4) the realization that they need similar hands-on care at home as in a hospital.

Conclusions

Although patients were satisfied with home-based chemotherapy, they were enduring the difficulties they experienced at home alone. Nurses should make an effort to identify patient needs and devise tailored nursing interventions to improve their safety.

A national Danish proof of concept on feasibility and safety of home -based intensive chemotherapy in patients with acute myeloid leukemia

Technological advances have made it possible to offer home-based chemotherapy to patients without health care professionals being present. Prior studies on effects of home-based treatment lack inclusion of patients with hematologic malignancies. We present data from a multicenter single-arm feasibility and safety study of home-based intensive chemotherapy in patients with newly diagnosed acute myeloid leukemia and their quality of life and psychological wellbeing. This national study included patients from six sites in Denmark who received intensive chemotherapy on programmed CADD Solis infusion pumps through a central venous catheter and were also managed as outpatients during treatment-induced pancytopenia. Data are presented from 104 patients, receiving 272 treatments with 1.096 (mean 4.57, SD 3.0) home infusion days out of 1.644 treatment days (67 %). Sixty-two of 168 (36.9 %) reinduction and consolidation treatment cycles ensuing pancytopenia phases were solely handled in the outpatient clinic. Patients reported high satisfaction with home-based treatment, which had a positive influence on their ability to be involved in their treatment and be socially and physically active. No unexpected events occurred during the intervention. Overall, patients improved in all quality of life outcomes over time. Home-based intensive chemotherapy treatment was feasible and safe in this population. ClinicalTrials.gov identifier: NCT04904211.

Evaluation of adverse events and health-related quality of life in patients with colorectal cancer receiving ambulatory home-based chemotherapy in Thailand

Aims

To compare adverse events and health‐related quality of life in ambulatory home‐based chemotherapy with those in inpatient.

Design

Prospective non‐randomized observational study.

Methods

Participants were divided into two groups according to patients’ preference receiving chemotherapy.

Results

Sixty‐four participants were enrolled in the inpatient, and 111 were in an ambulatory home‐based chemotherapy. The frequency of anaemia, neutropenia and thrombocytopenia was significantly higher in inpatient group than in ambulatory home‐based chemotherapy group (p < .001, <.001 and .002, respectively). Nausea, mucositis, and fatigue were more common in ambulatory home‐based chemotherapy group than in inpatient group (p < .001, .022, and .005, respectively). Patients in the ambulatory home‐based chemotherapy group showed higher social well‐being (SWB) scores than inpatient group (coefficient 1.92, 95% confidence interval [CI] 0.65 to 3.19, p .003).

Patient Safety and Satisfaction in Home Chemotherapy

Chemotherapy is increasingly being administered in patients' homes, improving quality of life and patient comfort as well as reducing use of inpatient facilities and costs. This article describes outcomes of home chemotherapy administered by trained nurses to adult patients with solid tumors or hematological diseases. This descriptive study was conducted between February 2018 and May 2020. Variables examined included age, sex, diagnosis, routes of administration, adverse effects, tolerance, and patient satisfaction. One hundred forty-seven patients (57.14% male) with an average age of 67.8 years agreed to participate. A total of 1018 chemotherapy sessions were examined. The most common diagnoses were prostate cancer, colon cancer, and high-risk myelodysplastic syndromes. Thirty-five percent (n = 356) of the sessions were conducted with: Azacytidine, 5-Fluoruracil, Oxaliplatin + Docetaxel + Leucovorin + Fluorouracil, and Leuprolide Acetate. The routes of administration included: intravenous (69.25%), intramuscular (13.75%), subcutaneous (15.32%), and intravesical (1.66%). Very good tolerance was reported after 87.81% of sessions and good after 8.45%. Adverse events during administration occurred in 7 sessions (0.7%); all were considered minor events. In the 24 hours following administration, 62 adverse events (6.1%) were reported, again all considered minor. All patients reported feeling just as safe as in the hospital. Our results contribute to the feasibility and safety of home chemotherapy.

Impacts on health outcomes and on resources utilization for anticancer drugs injection at home, a complex intervention: a systematic review

BACKGROUND

As hospital-based home care is a complex intervention, we critically appraised the key elements that could ensure the completeness of assessment and explain the heterogeneity of the literature results about the comparison between home and hospital setting for the anticancer drugs injection within the same standards of clinical care.

METHODS

Systematic review was conducted. Medline, Embase, Cochrane Library, Web of Sciences, and Cumulative Index of Nursing and Allied Health (Cinahl) searched to February 1, 2019, and combined with grey literature. Methodological quality has been rated using the "Quality Assessment Tool for Quantitative Studies" developed by the Effective Public Health Practice Project (EPHHP) in addition to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement for economic studies and the consolidated criteria for reporting qualitative research (COREQ) checklist for qualitative studies.

RESULTS

Of 400 records identified, we identified 13 relevant studies (nine quantitative and four mixed-method studies). The quality of studies was hardly strong. The home-based anticancer injection involved highly heterogeneous home care interventions that generally kept a strong link with the hospital setting. The study schemes limited the comparison of clinical outcomes (OS, PFS, toxicity). Unlike the quality of life remaining similar, patients preferred to be treated at home. Cost savings were in favor of Hospital at Home, but the charge categories used to compare or the home intervention were heterogeneous and rarely integrating relatives' duties and hospital staff's time. Qualitative studies highlighted about benefits and barriers of home.

CONCLUSION

The current state of evidence shows as it still remains difficult to appraise the anticancer injection at home when considering the details of this complex intervention, the role of each stakeholder, and the missing data.

Cancer care at home or in local health centres versus in hospital: Public policy goals and patients' preferences in the Rhône-Alps region in France

In France, cancer treatments are mainly provided in hospitals, which are expensive and crowded. Health decision-makers therefore want to develop alternative structures such as home care and local health centres.

OBJECTIVES

To elicit cancer patients' preferences for home, local health centre, or hospital, and analyze factors affecting these choices: patients' characteristics, experiences of care, expectations and perceptions of cancer management.

METHODS

We developed a decision aid composed of 1) information on the 3 options 2) a questionnaire to measure preferences; 3) a questionnaire on sociodemographics and experiences of care, 386 patients participated in the survey.

RESULTS

hospital was the preferred option for 71 % of the participants, especially for complicated care, followed by home care (24 %) and local health centres (5%). Main reasons for preferring hospital were the wish to separate home life and place of care, wanting to avoid being a burden on their relatives. Reasons influencing a preference for home care were wanting to avoid trips, maintain their lifestyle, and finding hospitals frightening. Neither socio-demographics nor even experience of care seemed to explain preferences.

CONCLUSION

A quarter of patients preferred home care, which is highly disproportionate to the home care currently available. This suggests that hindrances to developing alternatives to hospital do not come from patients' reluctance to make use of them, but rather from healthcare providers' objections.

Shifting specialized oncological care from hospital- to home-setting: is there support among patients, specialists and general practitioners?

OBJECTIVES

Oncological home-hospitalization (OHH) might be a patient-centred approach to deal with the increasing burden of cancer on health-care facilities and finances. Before implementation into practice, its feasibility, costs and support among stakeholders should be evaluated. The purpose of this trial was to explore patients', specialists' and general practitioners' (GPs) perspectives towards the opportunities of implementing OHH within the Belgian health-care system.

METHODS

A regional cross-sectional survey study was launched in order to investigate the stakeholders' views on OHH and the current cancer care focusing on integration of primary care and continuous care.

RESULTS

Of the responders, 37 out of 163 patients (23%), 45 of 62 GPs (73%) and 10 of 15 specialists (67%) feel positive about the opportunities for OHH. Nevertheless, 11/15 specialists (73%) and 51/62 GPs (82%) feel primary care might currently be (too) little involved in order to ensure continuous care for cancer patients. Opportunities for improved continuous care are seen in better communication between primary care and hospital, and more patient contacts for primary care during the cancer treatment process.

CONCLUSION

The results of this local survey study demonstrated there is support among different stakeholder groups for the implementation of OHH within the Belgian health-care context. However, some barriers impeding transmural continuous care should be tackled before implementing such model into practice. Better communication between health-care professionals and more patients contacts are suggested, and an adjusted legal and financial framework is required.

[E-health and "Cancer outside the hospital walls", Big Data and artificial intelligence]

To heal otherwise in oncology has become an imperative of Public Health and an economic imperative in France. Patients can therefore receive live most of their care outside of hospital with more ambulatory care. This ambulatory shift will benefit from the digital revolution and the development of digital health or e-health. Cancer research will also benefit with Big Data and artificial intelligence, which gather and analyze a huge amount of data. In this synthesis, we describe the different e-health tools and their potential impacts in oncology, at the levels of education and information of patients and caregivers, prevention, screening and diagnosis, treatment, follow-up, and research. A few randomized studies have already demonstrated clinical benefits. Large Big Data projects such as ConSoRe and Health Data Hub have been launched in France. We also discuss the issues and limitations of "cancer outside the hospital walls and e-health" from the point of view of patients, health care professionals, health facilities and government. This new organization will have to provide remote support "outside the walls" with care and follow-up of quality, continuous and prolonged in total safety and equity. Ongoing and future randomized clinical trials will need to definitively demonstrate areas of interest, advantages and drawbacks not only for patients, but also for caregivers, health facilities and governments.

Outpatient Cancer Care Delivery in the Context of E-Oncology: A French Perspective on "Cancer outside the Hospital Walls"

In oncology, the treatment of patients outside of hospitals has become imperative due to an increasing number of patients who are older and live longer, along with issues such as medical desertification, oncologist hyperspecialization, and difficulties in financing mounting health expenditures. Treatments have become less "invasive", with greater precision and efficiency. Patients can therefore receive most of their care outside of hospitals. The development of e-health can address these new imperatives. In this letter, we describe the different e-health tools and their potential clinical impacts in oncology, as already reported at every level of care, including education, prevention, diagnosis, treatment, and monitoring. A few randomized studies have yet demonstrated the clinical benefit. We also comment on issues and limits of "cancer outside the hospital walls" from the point of view of patients, health care professionals, health facilities, and public authorities. Care providers in hospitals and communities will have to adapt to these changes within well-coordinated networks in order to better meet patient expectations regarding increasing education and personalizing management. Ultimately, controlled studies should aim to definitively demonstrate areas of interest, benefits, and incentives, for not only patients, but also caregivers (formal and informal) and health care providers, health care facilities, and the nation.

Impacts on health outcomes and on resource utilisation of home-based parenteral chemotherapy administration: a systematic review protocol

INTRODUCTION

Despite the demonstrated feasibility and policies to enable more to receive chemotherapy at home, in a few countries, parenteral chemotherapy administration at home remains currently marginal. Of note, findings of different studies on health outcomes and resources utilisation vary, leading to conflicting results. This protocol outlines a systematic review that seeks to synthesise and critically appraise the current state of evidence on the comparison between home setting and hospital setting for parenteral chemotherapy administration within the same high standards of clinical care.

METHODS AND ANALYSIS

This protocol has been prepared following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols approach. Electronic searches will be conducted on bibliographic databases selected from the earliest available data through 15 November 2017 published in French and English languages. Additional potential papers in the selected studies and grey literature will be also included in the review. The review will include all types of studies exploring patients receiving anticancer drugs for injection at home compared with patients receiving the drugs in a hospital setting, and will assess at least one of the following criteria: patients' health outcomes, patients' or caregivers' satisfaction, resource utilisation with cost savings, and incentives and/or barriers of each admission setting according to patients' and relatives' points of view. Two reviewers will independently screen studies and extract relevant data from the included studies. Methodological quality of studies will be assessed using the 'Quality Assessment Tool for Quantitative Studies' developed by the Effective Public Health Practice Project tool, in addition to the Consolidated Health Economic Evaluation Reporting Standards statement for economic studies.

ETHICS AND DISSEMINATION

As the review is focused on the analysis of secondary data, it does not require ethics approval. The results of the study will be disseminated through articles in peer-reviewed journals and trade publications, as well as presentations at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42017068164.

Randomised trials comparing different healthcare settings: an exploratory review of the impact of pre-trial preferences on participation, and discussion of other methodological challenges

BACKGROUND

We recently published a systematic review of different healthcare settings (such as outpatient, community or home) for administering intravenous chemotherapy, and concluded that performing conventionally designed randomised trials was difficult. The main problems were achieving adequate trial accrual rates and recruiting a study population which adequately represented the target population of interest. These issues stemmed from the fact that potential participants may have had pre-trial perceptions about the trial settings they may be allocated; such preferences will sometimes be strong enough for patients to decline an invitation to participate in a trial. A patient preference trial design (in which patients can choose, or be randomised to, an intervention) may have obviated these recruitment issues, although none of the trials used such a design.

METHODS

In order to gain a better understanding of the broader prevalence and extent of these preference issues (and any other methodological challenges), we undertook an exploratory review of settings trials in any area of healthcare treatment research. We searched The Cochrane Library and Google Scholar and used snowballing methods to identify trials comparing different healthcare settings.

RESULTS

Trial accrual was affected by patient preferences for a setting in 15 of the 16 identified studies; birth setting trials were the most markedly affected, with between 68 % and 85 % of eligible women declining to participate specifically because of preference for a particular healthcare setting. Recruitment into substance abuse and chemotherapy setting studies was also notably affected by preferences. Only four trials used a preference design: the proportion of eligible patients choosing to participate via a preference group ranged from between 33 % and 67 %.

CONCLUSIONS

In trials of healthcare settings, accrual may be seriously affected by patient preferences. The use of trial designs which incorporate a preference component should therefore strongly be considered. When designing such trials, investigators should consider settings to be complex interventions, which are likely to have linked components which may be difficult to control for. Careful thought is also needed regarding the choice of comparator settings and the most appropriate outcome measures to be used.

Short article: Remicade infusions at home: an alternative setting of infliximab therapy for patients with Crohn's disease

OBJECTIVE

Infliximab maintenance treatment for Crohn's disease (CD) consists of intravenous infusions that are usually given at 6-8-week intervals. We aimed to evaluate whether home-based infliximab infusions could offer a useful and safe alternative for the management of CD patients.

METHODS

Adult CD patients receiving infliximab maintenance treatment at the Academic Medical Center in Amsterdam were invited to receive their infusions at home for the duration of 1 year. Patients had to be in clinical remission and should have had no adverse events during previous infusions. Patient satisfaction and experience were studied. Costs were analyzed and compared with hospital-based infliximab infusions.

RESULTS

Twenty-nine patients were invited, of whom 13 (45%) wanted to participate. Of the participants, 54% were female, and the median age was 33 years. In total, 59 infliximab infusions were administered at home at a median dose of 360 mg. The median rating of patient satisfaction was 8 on a scale from 1 to 10 for both home and hospital treatment settings. An important observation was that patients' willingness to participate would have been 70% if the possibility of receiving infusions at home outside office hours had been offered. Costs of infliximab infusions at home were €229 per infusion compared with €284 at the infusion clinic (excluding drug costs).

CONCLUSION

Home-based infliximab infusions were associated with a cost saving of €55 per infusion. Most participants were satisfied and would recommend home-based infusions to others. Infliximab treatment at home might be recommended as routine care for CD patients.

A multi-method review of home-based chemotherapy

This study summarises research- and practice-based evidence on home-based chemotherapy, and explores existing delivery models. A three-pronged investigation was conducted consisting of a literature review and synthesis of 54 papers, a review of seven home-based chemotherapy programmes spanning four countries, and two case studies within the Canadian province of Ontario. The results support the provision of home-based chemotherapy as a safe and patient-centred alternative to hospital- and outpatient-based service. This paper consolidates information on home-based chemotherapy programmes including services and drugs offered, patient eligibility criteria, patient views and experiences, delivery structures and processes, and common challenges. Fourteen recommendations are also provided for improving the delivery of chemotherapy in patients' homes by prioritising patient-centredness, provider training and teamwork, safety and quality of care, and programme management. The results of this study can be used to inform the development of an evidence-informed model for the delivery of chemotherapy and related care, such as symptom management, in patients' homes.

The delivery of chemotherapy at home: an evidence synthesis

Background

Recent policy and guidance has focused on chemotherapy services being offered closer to home, but the clinical and economic implications of this are uncertain.

Objectives

To compare the impact of delivering intravenous chemotherapy in different settings on a range of outcomes, including quality of life, safety and costs.

Design

Multimethods approach: systematic review of clinical effectiveness, qualitative and cost-effectiveness studies; description of the patient pathway and brief survey of current provision; and development of a decision model to explore aspects of cost-effectiveness.

Setting

Provision of intravenous chemotherapy.

Participants

Chemotherapy patients.

Interventions

Setting in which chemotherapy was administered (home, community or outpatient).

Outcome measures

Safety, quality of life, preference, satisfaction, opinions/experiences, social functioning, clinical outcomes, costs and resource/organisational issues.

Data sources

Sixteen electronic databases (including MEDLINE, EMBASE and The Cochrane Library) were searched from inception to October 2013 for published and unpublished studies.

Review methods

Two reviewers independently screened potentially relevant studies, extracted data and quality assessed the included studies. Study validity was evaluated using appropriate quality assessment tools. Clinical effectiveness and cost-effectiveness studies were summarised narratively, and qualitative studies were synthesised using meta-ethnography.

Results

Of the 67 eligible studies, 25 were comparative, with nine including a concurrent economic evaluation. Although some of the 10 randomised trials were designed to minimise avoidable biases, slow recruitment rates and non-participation of eligible patients for setting-related reasons meant that trial sample sizes were small and populations were inherently biased to favour the home or community settings. There was little evidence to suggest differences between settings in terms of quality of life, clinical outcomes, psychological outcomes or adverse events. All nine economic evaluations were judged as having low or uncertain quality, providing limited evidence to draw overall conclusions. Most were cost–consequence analyses, presenting cost outcomes alongside trial results but deriving no summary measure of benefit. Poor resource use reporting and use of different perspectives across settings made results difficult to compare. Seventeen qualitative studies (450 participants) were judged as moderate to good quality, although all compared new or proposed services with existing outpatient facilities and biased samples were used. The three main lines of argument were barriers to service provision, satisfaction with chemotherapy and making compromises to maintain normality. Most patients made explicit trade-offs between the time and energy required for outpatient chemotherapy, which reduced quality of life, and an increased sense of safety. A patient pathway was described, informed by expert advice and a brief survey of NHS and private providers, which identified wide variation in the ways in which home and community chemotherapy was delivered. Considering limitations of the available data and variation in provision, cost-effectiveness modelling results were not robust and were viewed as exploratory only; the results were highly unstable.

Conclusions

Primary studies comparing settings for administering intravenous chemotherapy appear difficult to conduct. Consequently, few robust conclusions can be made about the clinical effectiveness and cost-effectiveness. Qualitative studies indicate that the patient time and energy required for outpatient chemotherapy reduces quality of life. A nested randomised controlled trial within a larger observational cohort of patients is proposed to enhance recruitment and improve generalisability of results. Future economic evaluations require detailed patient characteristic, resource use, cost and quality-of-life data, although their results are likely to have limited generalisability.

Study registration

This study is registered as PROSPERO CRD42013004851.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Percepção dos residentes sobre sua atuação no programa de residência multiprofissional

Objetivo Compreender os significados das experiências de formação dos pós-graduandos do programa de Residência Multiprofissional em Saúde vinculado a uma instituição federal de ensino. Métodos Pesquisa exploratória, descritiva com abordagem qualitativa, realizada com pós-graduandos de um Programa de Residência Multiprofissional em Saúde. Realizada coleta de dados através de entrevista semiestruturada, sendo os dados obtidos nos discursos categorizados através da técnica de análise de conteúdo. Resultados Foram desveladas quatro categorías temáticas: a residência e prática multiprofissional, a residência como prática do trabalho em equipe, reconhecimento do trabalho do residente pelo usuário e a experiência da residência no contexto do trabalho em saúde. Conclusão O Programa de Residência Multiprofissional é compreendido como uma oportunidade significativa de aprendizado e contato com profissionais de diferentes áreas, onde se efetua o cuidado integral na prática profissional com a concientização de que a assistência deve contemplar os aspectos sociais, ambientais e psicológicos do indivíduo.