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Berkman AM, Andersen CR, Hildebrandt MAT, Livingston JA, Green AL, Puthenpura V, Peterson SK, Milam J, Miller KA, Freyer DR, Roth ME. Risk of early death in adolescents and young adults with cancer: a population-based study. J Natl Cancer Inst 2023; 115:447-455. [PMID: 36682385 PMCID: PMC10086632 DOI: 10.1093/jnci/djac206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/28/2022] [Accepted: 11/01/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Advancements in treatment and supportive care have led to improved survival for adolescents and young adults (AYAs) with cancer; however, a subset of those diagnosed remain at risk for early death (within 2 months of diagnosis). Factors that place AYAs at increased risk of early death have not been well studied. METHODS The Surveillance, Epidemiology, and End Results registry was used to assess risk of early death in AYAs with hematologic malignancies, central nervous system tumors, and solid tumors. Associations between age at diagnosis, sex, race, ethnicity, socioeconomic status, insurance status, rurality, and early death were assessed. RESULTS A total of 268 501 AYAs diagnosed between 2000 and 2016 were included. Early death percentage was highest in patients diagnosed with hematologic malignancies (3.1%, 95% confidence interval [CI] = 2.9% to 3.2%), followed by central nervous system tumors (2.5%, 95% CI = 2.3% to 2.8%), and solid tumors (1.0%, 95% CI = 0.9% to 1.0%). Age at diagnosis, race, ethnicity, lower socioeconomic status, and insurance status were associated with increased risk of early death in each of the cancer types. For AYAs with hematologic malignancies and solid tumors, risk of early death decreased statistically significantly over time. CONCLUSIONS A subset of AYAs with cancer remains at risk for early death. In addition to cancer type, sociodemographic factors also affect risk of early death. A better understanding of the interplay of factors related to cancer type, treatment, and health systems that place certain AYA subsets at higher risk for early death is needed to address these disparities and improve outcomes.
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Affiliation(s)
- Amy M Berkman
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Clark R Andersen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michelle A T Hildebrandt
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J A Livingston
- Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adam L Green
- Section of Pediatric Hematology, Oncology, and Bone Marrow Transplantation, University of Colorado School of Medicine, Aurora, CO, USA
| | - Vidya Puthenpura
- Section of Pediatric Hematology and Oncology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Susan K Peterson
- Division of Cancer Prevention and Control, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joel Milam
- Departments of Medicine and Epidemiology and Biostatistics, University of California, Irvine, CA, USA
| | - Kimberly A Miller
- Departments of Population and Public Health Sciences and Dermatology, Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
| | - David R Freyer
- Departments of Clinical Pediatrics, Medicine, and Population and Public Health Sciences, Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
| | - Michael E Roth
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Corrigan KL, Reeve BB, Salsman JM, Siembida EJ, Andring LM, Geng Y, Kouzy R, Livingston JA, Peterson SK, Bishop AJ, Smith GL, Gunther JR, Parsons SK, Roth M. Health-related quality of life in adolescents and young adults with cancer who received radiation therapy: a scoping review. Support Care Cancer 2023; 31:230. [PMID: 36961516 DOI: 10.1007/s00520-023-07682-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/10/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE Radiation therapy (RT) is a critical component of treatment for adolescents and young adults (AYAs, age 15-39 years old) diagnosed with cancer. Limited prior studies have focused on AYAs receiving RT despite the potentially burdensome effects of RT. We reviewed the literature to assess health-related quality of life (HRQOL) in AYAs with cancer who received RT. METHODS The MEDLINE, EMBASE, and Web of Science databases were searched in January 2022 to identify studies that analyzed HRQOL measured by patient-reported outcomes in AYAs who received RT. After title (n = 286) and abstract (n = 58) screening and full-text review (n = 19), articles that met eligibility criteria were analyzed. RESULTS Six studies were analyzed. Two studies included AYAs actively receiving treatment and all included patients in survivorship; time between diagnosis and HRQOL data collection ranged from 3 to > 20 years. Physical and mental health were commonly assessed (6/6 studies) with social health assessed in three studies. AYA-relevant HRQOL needs were rarely assessed: fertility (1/6 studies), financial hardship (1/6), body image (0/6), spirituality (0/6), and sexual health (0/6). No study compared HRQOL between patients actively receiving RT and those post-treatment. None of the studies collected HRQOL data longitudinally. CONCLUSION HRQOL data in AYAs receiving RT is limited. Future studies examining longitudinal, clinician- vs. patient-reported, and AYA-relevant HRQOL are needed to better understand the unique needs in this population.
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Affiliation(s)
- Kelsey L Corrigan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bryce B Reeve
- Center for Health Measurement, Department of Population Health Sciences, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - John M Salsman
- Department of Social Sciences and Health Policy, Wake Forest University, Winston-Salem, NC, USA
| | | | - Lauren M Andring
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yimin Geng
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ramez Kouzy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J Andrew Livingston
- Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan K Peterson
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Bishop
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jillian R Gunther
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan K Parsons
- Department of Medicine, Tufts University School of Medicine, ICRHPS, Tufts Medical Center, Boston, MA, USA
| | - Michael Roth
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Majdalani MP, Alazraqui M. Predominant approaches in studies on health-related quality of life of young survivors of childhood or adolescent cancer: an integrative literature review. CIENCIA & SAUDE COLETIVA 2022. [DOI: 10.1590/1413-81232022278.22132021en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Survivors of childhood cancer constitute a growing population. The disease experienced, its treatment or the occurrence of late complications may affect survivors’ health-related quality of life (HRQOL). Understanding HRQOL is a challenge due to its conceptual complexity and the mode in which it is studied. Objective: To identify the predominant lines of research in the study of HRQOL in this population. Methods: An integrative literature review was carried out, involving a systematic search of primary articles indexed in the Scopus and PubMed databases. Results: In the 48 publications selected, four main lines of research were identified: HRQOL in survivors in general; HRQOL in long-term survivors; the study of determinants of HRQOL; and the study of methodological aspects of HRQOL measurement. A quantitative approach using generic measurement instruments predominates, and the conceptual model of HRQOL based on function emphasizes the importance of physical, psychological, and social functionality and the impact of the disease and treatment on these aspects. Conclusions: incorporating a qualitative, meaning-based approach to the understanding of lived experiences from a subjective and holistic perspective is indispensable.
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4
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Majdalani MP, Alazraqui M. Predominant approaches in studies on health-related quality of life of young survivors of childhood or adolescent cancer: an integrative literature review. CIENCIA & SAUDE COLETIVA 2022; 27:3063-3077. [PMID: 35894319 DOI: 10.1590/1413-81232022278.22132021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 03/30/2022] [Indexed: 11/22/2022] Open
Abstract
Survivors of childhood cancer constitute a growing population. The disease experienced, its treatment or the occurrence of late complications may affect survivors' health-related quality of life (HRQOL). Understanding HRQOL is a challenge due to its conceptual complexity and the mode in which it is studied. OBJECTIVE To identify the predominant lines of research in the study of HRQOL in this population. METHODS An integrative literature review was carried out, involving a systematic search of primary articles indexed in the Scopus and PubMed databases. RESULTS In the 48 publications selected, four main lines of research were identified: HRQOL in survivors in general; HRQOL in long-term survivors; the study of determinants of HRQOL; and the study of methodological aspects of HRQOL measurement. A quantitative approach using generic measurement instruments predominates, and the conceptual model of HRQOL based on function emphasizes the importance of physical, psychological, and social functionality and the impact of the disease and treatment on these aspects. CONCLUSIONS incorporating a qualitative, meaning-based approach to the understanding of lived experiences from a subjective and holistic perspective is indispensable.
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Affiliation(s)
- María Pía Majdalani
- División de Medicina Interna General, Hospital de Clínicas "José de San Martín", Universidad de Buenos Aires. Buenos Aires Argentina.
| | - Marcio Alazraqui
- Instituto de Salud Colectiva, Universidad Nacional de Lanús. Buenos Aires Argentina
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Hand MW, Evans J, Swenty C, White A, Chen C. An Examination of Factors Associated With Student Resiliency. Nurse Educ 2022; 47:156-160. [PMID: 34669669 DOI: 10.1097/nne.0000000000001119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Student resiliency, success, and retention are top priorities for nursing programs. PURPOSE The purpose of the cross-sectional descriptive study was to identify factors associated with the resiliency level and physical and mental health of nursing students. METHODS A cross-sectional descriptive study design was used with a convenience sample of 199 nursing students from organizations that comprise the Community Patient Safety Coalition Nursing Research Consortium. Resiliency was measured with the Connor Davidson Resiliency Scale. Physical and mental health was measured with the Patient Reported Outcomes Measurement Information System Global Health Short Form. RESULTS Most of the nursing students in the sample were female (92%), White (94%), and in BSN programs (74.4%). Students had low resiliency (P < .0001) and low physical and mental health (P < .0001) compared with the general population. CONCLUSIONS Student resilience was positively correlated to self-perception of physical and mental health.
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Affiliation(s)
- Mikel W Hand
- Associate Professor of Nursing (Drs Hand, Evans, and Swenty), Assistant Dean (Dr Swenty), and Dean and Professor (Dr White), College of Nursing and Health Professions, University of Southern Indiana; and Assistant Professor (Dr Chen), Zhejiang University, Hangzhou, China
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Berkman AM, Murphy KM, Siembida EJ, Lau N, Geng Y, Parsons SK, Salsman JM, Roth ME. Inclusion of Patient-Reported Outcomes in Adolescent and Young Adult Phase III Therapeutic Trials: An Analysis of Cancer Clinical Trials Registered on ClinicalTrials.gov. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1820-1827. [PMID: 34838280 PMCID: PMC8630401 DOI: 10.1016/j.jval.2021.06.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 06/12/2021] [Accepted: 06/21/2021] [Indexed: 05/03/2023]
Abstract
OBJECTIVES There is a paucity of research on the impact of cancer treatment on the health-related quality of life (HRQOL) of adolescent and young adult (AYA) patients with cancer. Patient-reported outcomes (PROs) are self-report measures used to assess HRQOL and symptom burden. The extent to which PROs have been included in trials that include common AYA cancer types has not been previously assessed. METHODS Therapeutic phase 3 trials among common AYA cancer types (Hodgkin lymphoma, non-Hodgkin lymphoma, acute lymphoblastic leukemia, sarcomas, and germ cell tumors) initiated between 2007 and 2020 were identified on ClinicalTrials.gov. The proportions and characteristics of trials including a PRO endpoint were assessed. For comparison with an older population, the proportion of breast and colorectal therapeutic phase 3 trials including PRO endpoints were assessed. RESULTS Eighty-seven studies met the inclusion criteria. Overall, 20.7% of therapeutic phase 3 AYA trials included a PRO endpoint, and only one trial published PRO data. Germ cell tumors (42.9%) and non-Hodgkin lymphoma (40%) trials had the highest proportions of PRO inclusion. The European Organization for Research and Treatment of Cancer generic, cancer-specific quality of life questionnaire was the most commonly used PRO measure; nevertheless, the measures used varied within and between cancer types. The proportion of trials including a PRO endpoint did not change significantly between 2007 to 2013 and 2014 to 2020 (18.6% vs 22.7%, P=.79). CONCLUSIONS Few therapeutic phase 3 AYA cancer trials include PRO endpoints, fewer publish PRO data, and there is no homogeneity in the measures administered. Therapeutic trials represent an underused opportunity to capture PRO data in the AYA population with the goal of improving HRQOL outcomes.
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Affiliation(s)
- Amy M Berkman
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Karly M Murphy
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, USA
| | - Elizabeth J Siembida
- Center for Health Innovation and Outcomes Research, Northwell Health, Manhasset, NY, USA
| | - Nancy Lau
- Center for Clinical and Translational Research, Palliative Care and Resilience Research Center, Seattle Children's Research Institute, Seattle, WA, USA; Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Yimin Geng
- Research Medical Library, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan K Parsons
- Institute for Clinical Research and Health Policy Studies and the Division of Hematology/Oncology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - John M Salsman
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, USA
| | - Michael E Roth
- Division of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Downing KF, Oster ME, Klewer SE, Rose CE, Nembhard WN, Andrews JG, Farr SL. Disability Among Young Adults With Congenital Heart Defects: Congenital Heart Survey to Recognize Outcomes, Needs, and Well-Being 2016-2019. J Am Heart Assoc 2021; 10:e022440. [PMID: 34666499 PMCID: PMC8751822 DOI: 10.1161/jaha.121.022440] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Disabilities have implications for health, well‐being, and health care, yet limited information is available on the percentage of adults with congenital heart defects (CHD) living with disabilities. We evaluated the prevalence of disability and associated characteristics among the 2016–2019 CH STRONG (Congenital Heart Survey to Recognize Outcomes, Needs, and Well‐Being) population‐based sample of 19‐ to 38‐year‐olds with CHD from 3 US locations. Methods and Results Prevalence of disability types (hearing, vision, cognition, mobility, self‐care, living independently) were compared with similarly aged adults from the general population as estimated by the American Community Survey and standardized to the CH STRONG eligible population to reduce nonresponse bias and confounding. Health‐related quality of life (HRQOL) was measured via Patient‐Reported Outcomes Measurement Information System Global Health Scale T‐scores standardized to US 18‐ to 34‐year‐olds. Separate multivariable regression models assessed associations between disability and HRQOL. Of 1478 participants, 40% reported disabilities, with cognition most prevalent (29%). Of those reporting disability, 45% ever received disability benefits and 46% were unemployed. Prevalence of disability types were 5 to 8 times higher in adults with CHD than the general population. Those with ≥1 disability had greater odds of being female, and of having non‐Hispanic Black maternal race and ethnicity, severe CHD, recent cardiac care, and noncardiac congenital anomalies. On average, adults with CHD and cognition, mobility, and self‐care disabilities had impaired mental HRQOL and those with any disability type had impaired physical HRQOL. Conclusions Two of 5 adults with CHD may have disabilities, which are associated with impaired HRQOL. These results may inform healthcare needs and services for this growing population.
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Affiliation(s)
- Karrie F Downing
- National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention Atlanta GA
| | - Matthew E Oster
- National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention Atlanta GA.,Children's Healthcare of Atlanta and Emory University School of Medicine Atlanta GA
| | - Scott E Klewer
- Department of Pediatrics University of Arizona Tucson AZ
| | - Charles E Rose
- National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention Atlanta GA
| | - Wendy N Nembhard
- Department of Epidemiology Fay W Boozman College of Public Health and the Arkansas Center for Birth Defects Research and Prevention University of Arkansas for Medical Sciences Little Rock AR
| | | | - Sherry L Farr
- National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention Atlanta GA
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Bradford N, Pitt E, Rumble S, Cashion C, Lockwood L, Alexander K. Persistent Symptoms, Quality of Life, and Correlates with Health Self-Efficacy in Adolescent and Young Adult Survivors of Childhood Cancer. J Adolesc Young Adult Oncol 2021; 11:410-418. [PMID: 34582267 DOI: 10.1089/jayao.2021.0104] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Purpose: The numbers of adolescent and young adult (AYA) survivors of childhood cancer are exponentially growing. To ensure suitable services are available to meet the needs of this growing population, understanding the experience of late effects, quality of life, and potentially modifiable factors, such as self-efficacy, is required. Methods: AYA survivors of childhood cancer recruited through an After Cancer Therapy Service at a Children's Hospital rated their symptoms experience, quality of life, and self-efficacy using the Patient Reported Outcome Common Terminology Criteria for Adverse Events, Functional Assessment of Cancer Therapy-General (FACT-G), and Patient-Reported Outcomes Measurement Information System (PROMIS®), respectively. Descriptive statistics were used to characterize the sample. Quality-of-life scores were compared with population norms. Regression analyses were used to explore the relationships between symptom experience, quality of life, and self-efficacy. Results: Thirty participants (mean age 22 ± 4.4 years) reported an average of nine symptoms as persistently experienced at moderate or higher rated intensity among participants (standard deviation ±8.7; range: 0-32; interquartile range: 2-16); over half (n = 17, 56.7%) had finished treatment 10 or more years ago. Participants scored lower on the FACT-G Physical Well-being and Emotional Well-being, and higher on Social Well-being subscales than the general population. Around two-thirds of participants were confident in their ability to self-manage their health based on their health self-efficacy score. Bivariate linear regression identified a statistically significant increase in the overall quality of life with increased self-efficacy, adjusted for age and sex (0.60, 95% confidence interval [CI] 0.30-0.90, p < 0.01). Higher symptom burden was associated with a lower overall quality of life after adjusting for age and sex (-0.95, 95% CI: -1.35 to -0.54, p < 0.001). Conclusion: Young cancer survivors experience a substantial number of persistent symptoms related to their cancer treatment that may negatively impact aspects of their quality of life. Health self-efficacy is a potential target for future interventions.
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Affiliation(s)
- Natalie Bradford
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia.,Cancer and Palliative Care Outcomes Centre at Centre for Children's Health Research, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Erin Pitt
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia.,Cancer and Palliative Care Outcomes Centre at Centre for Children's Health Research, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Shelley Rumble
- Oncology Services Group, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, South Brisbane, Australia
| | - Christine Cashion
- Oncology Services Group, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, South Brisbane, Australia
| | - Liane Lockwood
- Oncology Services Group, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, South Brisbane, Australia
| | - Kimberly Alexander
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia.,Cancer and Palliative Care Outcomes Centre at Centre for Children's Health Research, Faculty of Health, Queensland University of Technology, Brisbane, Australia
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9
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Azad AD, Yilmaz M, Bozkurt S, Brooks JD, Blayney DW, Hernandez-Boussard T. Diverse patient trajectories during cytotoxic chemotherapy: Capturing longitudinal patient-reported outcomes. Cancer Med 2021; 10:5783-5793. [PMID: 34254459 PMCID: PMC8419778 DOI: 10.1002/cam4.4124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/16/2021] [Accepted: 06/21/2021] [Indexed: 12/24/2022] Open
Abstract
Background High‐value cancer care balances effective treatment with preservation of quality of life. Chemotherapy is known to affect patients’ physical and psychological well‐being negatively. Patient‐reported outcomes (PROs) provide a means to monitor declines in a patients’ well‐being during treatment. Methods We identified 741 oncology patients undergoing chemotherapy in our electronic health record (EHR) system who completed Patient‐Reported Outcomes Measurement Information System (PROMIS) surveys during treatment at a comprehensive cancer center, 2013–2018. PROMIS surveys were collected before, during, and after chemotherapy treatment. Linear mixed‐effects models were performed to identify predictors of physical and mental health scores over time. A k‐mean cluster analysis was used to group patient PROMIS score trajectories. Results Mean global physical health (GPH) scores were 48.7 (SD 9.3), 47.7 (8.8), and 48.6 (8.9) and global mental health (GMH) scores were 50.4 (8.6), 49.5 (8.8), and 50.6 (9.1) before, during, and after chemotherapy, respectively. Asian race, Hispanic ethnicity, public insurance, anxiety/depression, stage III cancer, and palliative care were predictors of GPH and GMH decline. The treatment time period was also a predictor of both GPH and GMH decline relative to pre‐treatment. Trajectory clustering identified four distinct PRO clusters associated with chemotherapy treatment. Conclusions Patient‐reported outcomes are increasingly used to help monitor cancer treatment and are now a part of care reimbursement. This study leveraged routinely collected PROMIS surveys linked to EHRs to identify novel patient trajectories of physical and mental well‐being in oncology patients undergoing chemotherapy and potential predictors. Supportive care interventions in high‐risk populations identified by our study may optimize resource deployment. Novelty and impact This study leveraged routinely collected patient‐reported outcome (PROMIS) surveys linked to electronic health records to characterize oncology patients’ quality of life during chemotherapy. Important clinical and demographic predictors of declines in quality of life were identified and four novel trajectories to guide personalized interventions and support. This work highlights the utility of monitoring patient‐reported outcomes not only before and after, but during chemotherapy to help advert adverse patient outcomes and improve treatment adherence.
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Affiliation(s)
- Amee D Azad
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Melih Yilmaz
- Department of Medicine (Biomedical Informatics, Stanford University School of Medicine, Stanford, California, USA
| | - Selen Bozkurt
- Department of Medicine (Biomedical Informatics, Stanford University School of Medicine, Stanford, California, USA
| | - James D Brooks
- Department of Urology, Stanford University School of Medicine, Stanford, California, USA
| | - Douglas W Blayney
- Department of Medicine, Division of Medical Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Tina Hernandez-Boussard
- Department of Medicine (Biomedical Informatics, Stanford University School of Medicine, Stanford, California, USA.,Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, California, USA
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10
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McKay GE, Zakas AL, Osman F, Lee-Miller C, Pophali P, Parkes A. Disparities Between Provider Assessment and Documentation of Care Needs in the Care of Adolescent and Young Adult Patients With Sarcoma. JCO Oncol Pract 2021; 17:e891-e900. [PMID: 33852368 DOI: 10.1200/op.20.00938] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Given the occurrence of cancer during a complex developmental time, adolescent and young adult (AYA) patients have unique psychosocial needs that necessitate supportive care, which is optimally provided using National Comprehensive Cancer Network (NCCN) AYA guidelines. We sought to explore compliance with NCCN AYA guidelines and compare with oncology providers' perceptions of AYA care needs. METHODS Retrospective chart reviews of AYA patients (15-39 years at time of cancer diagnosis) with sarcoma seen at least once in 2019 at the University of Wisconsin identified documentation of discussions deemed critical per NCCN AYA guidelines. As per the ASCO Quality Oncology Practice Initiative certification, we considered a threshold of these factors being discussed 75% of the time or higher to be compliant. Compliance was compared with an electronic survey of University of Wisconsin oncology providers regarding AYA patient needs, with items determined to have adequate resources if noted sufficient by at least 75% of providers. RESULTS We identified 43 AYA patients with sarcoma. Less than 75% of patients had documentation of discussion of contraception, sexual health, fertility, finances, genetics, social work referral, and clinical trials indicating noncompliance with NCCN guidelines. Surveys, completed by 38 oncology providers, showed significant discordance between providers' perceptions of AYAs' access to resources and providers' documented discussions of supportive care resources. CONCLUSION Disparities between oncology provider assessment of AYA care needs and documentation of critical components of AYA patient care demonstrate the need for novel tools to evaluate AYA care needs beyond provider assessments.
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Affiliation(s)
- Grace E McKay
- Division of Hematology, Medical Oncology, and Palliative Care, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Anna L Zakas
- Division of Oncology Genetics, Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Fauzia Osman
- Division of Hematology, Medical Oncology, and Palliative Care, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Cathy Lee-Miller
- Division of Hematology, Oncology and Bone Marrow Transplant, Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Priyanka Pophali
- Division of Hematology, Medical Oncology, and Palliative Care, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Amanda Parkes
- Division of Hematology, Medical Oncology, and Palliative Care, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
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11
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Haines ER, Lux L, Smitherman AB, Kessler ML, Schonberg J, Dopp A, Stover AM, Powell BJ, Birken SA. An actionable needs assessment for adolescents and young adults with cancer: the AYA Needs Assessment & Service Bridge (NA-SB). Support Care Cancer 2021; 29:4693-4704. [PMID: 33511477 DOI: 10.1007/s00520-021-06024-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/21/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE In the USA, many of the nearly 90,000 adolescents and young adults (AYAs) diagnosed with cancer each year do not receive services to address the full scope of needs they experience during and after cancer treatment. To facilitate a systematic and patient-centered approach to delivering services to address the unmet needs of AYAs with cancer, we developed the AYA Needs Assessment & Service Bridge (NA-SB). METHODS To develop NA-SB, we leveraged user-centered design, an iterative process for intervention development based on prospective user (i.e., provider and AYA) engagement. Specifically, we conducted usability testing and concept mapping to refine an existing tool-the Cancer Needs Questionnaire-Young People-to promote its usability and usefulness in routine cancer practice. RESULTS Our user-centered design process yielded a need assessment which assesses AYAs' physical, psychosocial, and practical needs. Importantly, needs in the assessment are grouped by services expected to address them, creating an intuitive and actionable link between needs and services. CONCLUSION NA-SB has the potential to improve care coordination at the individual level by allowing cancer care programs to tailor service delivery and resource provision to the individual needs of AYAs they serve.
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Affiliation(s)
- Emily R Haines
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, 525 Vine Street, Winston-Salem, NC, 27101, USA.
| | - Lauren Lux
- UNC Adolescent and Young Adult Cancer Program, Lineberger Comprehensive Cancer Center, 101 Manning Dr, Chapel Hill, NC, 27514, USA
| | - Andrew B Smitherman
- Pediatric Hematology-Oncology, Lineberger Comprehensive Cancer Center, 101 Manning Dr, Chapel Hill, NC, 27514, USA
| | - Melody L Kessler
- Department of Chemistry, University of North Carolina at Chapel Hill, 125 South Road, Chapel Hill, NC, 27599-3290, USA
| | - Jacob Schonberg
- Center for Excellence in Community Mental Health, Department of Psychiatry, University of North Carolina School of Medicine, 3010 Falstaff Rd, Raleigh, NC, 27610, USA
| | - Alex Dopp
- RAND Corporation, 1776 Main St, Santa Monica, CA, 90401, USA
| | - Angela M Stover
- Department of Health Policy & Management, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27516, USA
| | - Byron J Powell
- Brown School & School of Medicine, Washington University in St. Louis, 1 Brookings Dr, St. Louis, MO, 63130, USA
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest School of Medicine, 525@Vine Room 5219, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
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12
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Anderson LM, Papadakis JL, Vesco AT, Shapiro JB, Feldman MA, Evans MA, Weissberg-Benchell J. Patient-Reported and Parent Proxy-Reported Outcomes in Pediatric Medical Specialty Clinical Settings: A Systematic Review of Implementation. J Pediatr Psychol 2020; 45:247-265. [PMID: 31710671 DOI: 10.1093/jpepsy/jsz082] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/10/2019] [Accepted: 09/20/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Youth with chronic illness are at higher risk for psychosocial difficulties, leading to a call for screening via patient-reported outcomes (PROs). The purpose of the current review is to summarize PRO implementation in pediatric medical specialty settings. A literature review of PRO implementation in these settings, conceptual issues, value and approach, legal and ethical concerns, as well as a case example of PROA in type 1 diabetes are presented. METHODS A systematic review was conducted to identify relevant articles published since the most recent Journal of Pediatric Psychology Special Issue on Evidence-Based Assessment in Pediatric Psychology (2008). RESULTS Thirty-two articles were identified and reviewed. The majority of studies reported that PROA was feasible, did not disrupt clinic flow, identified psychosocial issues warranting intervention, and was acceptable to families and providers. Response to elevated scores and impact on behavioral health referrals varied. CONCLUSION While many evidenced-based assessment measures are well-validated within pediatric chronic illness groups, the literature regarding implementation of PROs is still emerging. Research findings are promising, with PROs being feasible, acceptable, and leading to increased discussion of psychosocial issues when integrated into pediatric medical settings. Additional research is needed to evaluate the longitudinal impact of PROs and the optimal manner of responding to assessment data, particularly when clinically-elevated. Ultimately, identifying psychosocial issues in pediatric medical settings can promote optimal health and well-being of youth with chronic illness and their families.
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Affiliation(s)
| | | | - Anthony T Vesco
- Ann and Robert H. Lurie Children's Hospital of Chicago.,Northwestern University Feinberg School of Medicine
| | | | - Marissa A Feldman
- Child Development and Rehabilitation Center, Johns Hopkins All Children's Hospital
| | - Meredyth A Evans
- Ann and Robert H. Lurie Children's Hospital of Chicago.,Northwestern University Feinberg School of Medicine
| | - Jill Weissberg-Benchell
- Ann and Robert H. Lurie Children's Hospital of Chicago.,Northwestern University Feinberg School of Medicine
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13
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Siembida EJ, Reeve BB, Zebrack BJ, Snyder MA, Salsman JM. Measuring health-related quality of life in adolescent and young adult cancer survivors with the National Institutes of Health Patient-Reported Outcomes Measurement Information System ® : Comparing adolescent, emerging adult, and young adult survivor perspectives. Psychooncology 2020; 30:303-311. [PMID: 33073416 DOI: 10.1002/pon.5577] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/10/2020] [Accepted: 10/13/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Our knowledge of symptom burden and functioning among adolescent and young adult (AYA; diagnosed ages 15-39) cancer survivors has been hindered by variability in health-related quality of life (HRQOL) measurement associated with developmental and disease heterogeneity among AYAs. We aimed to examine the variability in domain-specific aspects of HRQOL as a function of cancer type and developmental stage to clarify commonalities and differences using the NIH Patient-Reported Outcome Measurement Information System® . METHODS Five hundred seventy-two AYAs were recruited by an online research panel using stratified sampling (treatment status: on vs. off; developmental stage: adolescents, emerging adults, young adults). Participants completed questionnaires that included sociodemographic characteristics, clinical history, and the adult version of the Patient-Reported Outcomes Measurement Information System® -29 (PROMIS-29). Generalized linear models were run for each HRQOL domain and included treatment status, developmental stage, and cancer type (hematologic vs. solid tumor) and their interactions as independent variables. RESULTS There were no significant differences in any HRQOL domain by cancer type, and few significant differences were observed in PROMIS domains between developmental groups among on-treatment AYA survivors. In contrast, off-treatment emerging adults and young adults reported significantly higher symptoms and worse functioning compared to adolescents (all ps ≤ 0.003). CONCLUSIONS AYAs diagnosed in different developmental stages, particularly among off-treatment survivors, experienced diverse constellations of symptoms and functioning, and developmental stage was a more critical predictor of HRQOL than cancer type. These results suggest that supportive care interventions developed for AYA cancer survivors must be tailored and flexible by developmental stage and treatment status.
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Affiliation(s)
- Elizabeth J Siembida
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
| | - Bryce B Reeve
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Brad J Zebrack
- School of Social Work, University of Michigan, Ann Arbor, Missouri, USA
| | - Mallory A Snyder
- Office of Research and National Laboratories, The University of Chicago, Illinois, Chicago, USA
| | - John M Salsman
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine & the Wake Forest Baptist Comprehensive Cancer Center, North Carolina, Winston-Salem, USA
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14
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The Role of e-Health in the Delivery of Care for Patients with Hematological Cancers: A Systematic Literature Review. Telemed J E Health 2020; 26:1093-1105. [DOI: 10.1089/tmj.2019.0231] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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15
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van Deuren S, Boonstra A, van Dulmen‐den Broeder E, Blijlevens N, Knoop H, Loonen J. Severe fatigue after treatment for childhood cancer. Cochrane Database Syst Rev 2020; 3:CD012681. [PMID: 32124971 PMCID: PMC7059965 DOI: 10.1002/14651858.cd012681.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Treatment strategies for childhood cancer are improving, resulting in higher survival rates. However, the consequences of childhood cancer do not end with the successful completion of cancer treatment. Most patients will develop late effects after cessation of treatment. Severe fatigue is seen as a common and debilitating late effect in cancer survivors. Although most research on fatigue has been performed in patients after adult-onset cancer, our review focuses on fatigue after childhood cancer. OBJECTIVES To estimate the prevalence of severe fatigue after treatment for childhood cancer. Secondary objectives are to describe the course of severe fatigue following cancer treatment and to examine risk factors for fatigue, or factors associated with it. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (the Cochrane Library 2019; issue 8 March 2019), MEDLINE/PubMed (from 1945 to 8 March 2019), Embase/Ovid (from 1947 to 8 March 2019), reference lists of included articles and several conference proceedings from 2011 to 2018. SELECTION CRITERIA Observational studies, randomised controlled trials and controlled clinical trials reporting on fatigue in participants after treatment for childhood cancer. Case series and case reports were not eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risks of bias. If the publication did not present the prevalence of severe fatigue, we contacted study authors for additional information. MAIN RESULTS We included 30 studies (18,682 participants in total). Eighteen studies contributed to the main objective and 22 studies contributed to the secondary objectives. We found substantial differences between studies in cancer diagnosis, cancer treatment, age of participants, questionnaires used to assess fatigue, and sample size. All included studies scored at least one 'Risk of bias' item as unclear or high risk. We identified both clinical and statistical heterogeneity and therefore could not pool results, so we present them descriptively. Eighteen studies (describing 14,573 survivors) reported the prevalence of severe fatigue, which ranged from 0% to 61.7%. In a subgroup of three studies including children aged up to 18 years at fatigue assessment (268 survivors), prevalence rates ranged from 6.7% to 12.5%. In comparison, in a subgroup of 12 studies including participants aged 16 and over (13,952 survivors), prevalence rates ranged from 4.4% to 61.7%. The prevalence of severe fatigue in a subgroup of survivors of haematological cancer was presented in seven studies and ranged from 1.8% to 35.9% (1907 survivors). Prevalence of severe fatigue in brain cancer survivors was presented in two studies (252 survivors) and was 14.6% and 21.1% respectively. One study presented a prevalence for bone cancer survivors of 0.0% (17 survivors). Four studies provided prevalence rates of severe fatigue in control groups of siblings or population-based controls, which ranged from 3.1% to 10.3%. In these four studies, survivors were more often fatigued than controls, but this difference was statistically significant in only two studies. Studies assessing risk and associated factors for fatigue were heterogeneous, and definitions of the factors under study were often inconsistent, with results therefore presented descriptively. They found that depression might be associated with fatigue. In contrast, age at diagnosis and education level did not seem to be associated with fatigue. We were unable to calculate any overall risk estimate for any of the reported risks and associated factors, because we could not conduct meta-analysis. One study provided information about the course of fatigue over time, and found that over the course of 2.7 years, 32 of the 102 participants (31.4%) reported persistent severe fatigue. AUTHORS' CONCLUSIONS It is unclear how many childhood cancer survivors suffer from severe fatigue. This review encountered several difficulties. We found statistical and clinical heterogeneity and great variation in the reporting of possible risk and associated factors. The evidence in this review is therefore weak, and the exact prevalence of severe fatigue after treatment for childhood cancer remains to be determined. This is also the case for the course of severe fatigue following treatment and the strength of the relationship between fatigue and associated and risk factors. Despite these limitations, our review does provide a comprehensive overview of the existing literature about severe fatigue after treatment for childhood cancer.
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Affiliation(s)
- Sylvia van Deuren
- Radboud University Medical CenterDepartment of HematologyGeert Grooteplein Zuid 8NijmegenNetherlands6500 HB
| | - Amilie Boonstra
- Radboud University Medical CenterDepartment of HematologyGeert Grooteplein Zuid 8NijmegenNetherlands6500 HB
| | - Eline van Dulmen‐den Broeder
- Amsterdam UMC, Vrije Universiteit AmsterdamDepartment of Pediatrics, Division of Oncology/HematologyPO Box 7057AmsterdamNetherlands1007 MB
| | - Nicole Blijlevens
- Radboud University Medical CenterDepartment of HematologyGeert Grooteplein Zuid 8NijmegenNetherlands6500 HB
| | - Hans Knoop
- Amsterdam UMC, University of AmsterdamDepartment of Medical PsychologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Jacqueline Loonen
- Radboud University Medical CenterDepartment of HematologyGeert Grooteplein Zuid 8NijmegenNetherlands6500 HB
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16
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Snaman J, McCarthy S, Wiener L, Wolfe J. Pediatric Palliative Care in Oncology. J Clin Oncol 2020; 38:954-962. [PMID: 32023163 DOI: 10.1200/jco.18.02331] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Pediatric palliative care aims to alleviate suffering and improve the quality of life of children with serious disease and increase support for their parents and other family members. Integration of palliative care into the routine care of children, adolescents, and young adults with cancer has resulted in improved outcomes in patients and their families. The field of pediatric palliative oncology-encompassing primary palliative care provided by the multidisciplinary oncology team as well as subspecialty palliative care provided by the palliative care team for more complex cases-is unique from palliative care in adults given its focus on care of the child and the larger family. In this review, we focus on advancements in the specific domains within pediatric palliative oncology care including family-centered communication, assessment and management of physical symptoms and distress, psychosocial concerns, and spiritual considerations of the patient, parents, and siblings.
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Affiliation(s)
- Jennifer Snaman
- Dana-Farber Cancer Institute, Boston, MA.,Boston Children's Hospital, Boston, MA
| | | | - Lori Wiener
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Joanne Wolfe
- Dana-Farber Cancer Institute, Boston, MA.,Boston Children's Hospital, Boston, MA
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17
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Walsh C, Jang Y, Currin-McCulloch J, Simon P, Cubbin C, Jones B. Pilot Use of Selected Measures from the Patient-Reported Outcomes Measurement Information System Social and Mental Health Domains with Young Adult Cancer Patients During the Transition to Survivorship Care. J Adolesc Young Adult Oncol 2019; 8:635-639. [PMID: 31242051 PMCID: PMC6791479 DOI: 10.1089/jayao.2019.0022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Social reintegration is an important part of young adult cancer patients' transition to survivorship care. As part of a mixed methods study exploring the social functioning of young adult cancer patients during this transition process, participants (N = 13) completed four selected measures from the Patient-Reported Outcomes Measurement Information System (PROMIS) social and mental health domains within ∼6 months of completion of active treatment and 3 months later. The majority of participants (n = 10) had T-scores within normal limits on all measures. Three participants had T-scores in the mild or moderate impairment range across time points. No significant differences were found between groups at Time 1 and Time 2 on any of the four measures.
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Affiliation(s)
- Casey Walsh
- School of Public Health, Department of Health Services, The University of Washington, Seattle, Washington
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Yuri Jang
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California
| | | | - Pamela Simon
- Stanford Adolescent and Young Adult Cancer Program, Lucile Packard Children's Hospital, Palo Alto, California
| | - Catherine Cubbin
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, Texas
| | - Barbara Jones
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, Texas
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18
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Barr RD, Feeny DA. Health-related quality of life in adolescents and young adults with cancer - Including a focus on economic evaluation. Pediatr Blood Cancer 2019; 66:e27808. [PMID: 31081602 DOI: 10.1002/pbc.27808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 04/27/2019] [Accepted: 04/27/2019] [Indexed: 11/12/2022]
Abstract
Health-related quality of life (HRQL) is an amalgam of three elements - the opportunities that a person's health status affords, the constraints that it places upon the person and the value that a person places on his/her health status. HRQL measures are specific, for example for a disease, or generic with broad applicability. The latter include preference-based measures that can be used to generate quality-adjusted life years and so contribute to economic evaluation. Measures of HRQL in adolescents and young adults (AYAs) with cancer may fail to capture some important dimensions, for example sexual health. However, the use of HRQL measures in this population has identified burdens of morbidity according to disease, treatment status and duration of follow-up. There are few economic evaluations of the treatment of cancer in AYAs but preliminary evidence suggests that this is a cost-effective undertaking. Opportunities abound to include measurement of HRQL in routine clinical care.
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Affiliation(s)
- Ronald D Barr
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - David A Feeny
- Department of Economics, McMaster University, Hamilton, Ontario, Canada.,Health Utilities Incorporated, Dundas, Ontario, Canada
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