A model to estimate human resource needs for the treatment of outpatients with cancer

Optimizing chemotherapy medication leftover management circuit in a centralized chemotherapy preparation unit: A comprehensive FMECA risk analysis and continuous improvement approach

OBJECTIVE

Chemotherapy medications are usually having high costs, and new targeted drugs can be especially expensive, representing a challenge on healthcare, particularly in low- and middle-income countries. As cytotoxic leftover management is crucial for reducing medication wastage, the aim of this study is to evaluate and optimize leftover management circuit in NIO'S Pharmacy Centralized Chemotherapy Preparation Unit (CCPU) through a Failure Mode, Effects and Criticality Analysis (FMECA), and propose continuous improvement element to enhance the security of the process.

METHOD

The FMECA were conducted in NIO's CCPU from March to May 2023, then continuous improvement plan was established to enhance the security of the process. The failure modes, their causes, impact, and criticality were assessed through criticality index calculation (CI = severity × frequency × detectability), and the risk concerned safety and effectiveness disruptions in chemotherapy preparation circuit using cytotoxic leftover.

RESULTS

Leftover management circuits were described in flowchart form, where 18 failure modes were detected in four different steps of the process from chemotherapy preparation to disposal. Failure with highest critical index were detected in the case of equipment malfunction, improper storage temperature, and humidity. Continuous improvement recommendations were proposed in a table form.

CONCLUSION

FMECA analysis applied to NIO's chemotherapy leftover management process allowed us to evaluate, secure, and optimize the circuit, and to propose several actions to implement in a perspective of continuous improvement.

Analysis of workload generated in the two years following first consultation by each new cancer patient: studying the past to plan the future of cancer care

Introduction

Prevalence of cancer patients is dramatically increasing. We aimed at quantifying the oncology workload generated by each new cancer patient in the two years following first consultation.

Methods

In this record-based retrospective study, we retrieved data of all newly diagnosed patients treated at the Oncology Department of Udine Academic Hospital between 01.01.2012 and 31.12.2017. We calculated mean number and standard deviation of the activity type generated by each new cancer patient during the following 2 years.

Results

Seven thousand four hundred fifty-two cancer patients generated a total of 85,338 clinical episodes. The two-years mean number of oncology episodes generated was 11.31 (i.e., for every 1,000 new cancer patients, 11,310 oncology activities are generated overall in the following two-year lapse). Patients with advanced disease generated the highest workload (24.3; SD 18.8) with a statistically significant difference compared to adjuvant and follow-up patients (p < 0.001). The workload generated in the period 0–6 and 0–12 months was significantly higher than in the following months (p < 0.001) and it was also higher for patients initially designated to treatment (p < 0.001).

Conclusion

This is the first study reporting on the mean oncology workload generated during the 2 years following first consultation. Workload is the highest for patient with advanced disease, especially in the first months and in patients in active treatment. A detailed analysis of workloads in oncology is feasible and could be crucial for planning a sustainable framework for cancer care in the next future.

Randomized trial of a web-based nurse education intervention to increase discussion of clinical trials

Background

Clinical trials are a critical source of evidence for oncology care, yet very few patients participate. Among healthcare providers, nurses spend the most time with cancer patients and are the most highly trusted professionals. We developed and evaluated an educational program for oncology nurses targeting knowledge, attitudes, self-efficacy and perceived norms to facilitate discussion about clinical trials and support patient decision making.

Methods

A nationwide sample of oncology nurses were randomly assigned to receive general clinical trials education delivered as text (attention control) vs. tailored video vignettes (intervention) in a web-based continuing education program. Participants completed a baseline assessment and follow up assessments immediately after the educational program and three months later. The primary outcome was intention to discuss clinical trials with patients. Secondary outcomes were knowledge and attitudes about clinical trials, self-efficacy, and perceived norms.

Results

1393 nurses enrolled and completed the educational program and post-intervention assessment (720 control, 673 video). Both text education and tailored video education increased intention to discuss clinical trials with patients, with a greater effect in the video group (p < .0001). Likewise, knowledge, attitudes, perceived behavioral control, and perceived norms were all improved with education in both groups, and the magnitude of benefit was greater (p < .001) for the video group in all outcomes except knowledge.

Conclusion

A one-time online educational program for oncology nurses improves knowledge, attitudes, self-efficacy and intention to engage patients in discussions about clinical trials. A tailored video format was associated with a greater effect than standard text only material.

Recruitment Strategies for Nurse Enrollment in an Online Study

BACKGROUND

Although there is a great deal of literature regarding effective recruitment and challenges of recruiting specific patient populations, there is less known about best practices for recruitment of nurses as study subjects.

OBJECTIVES

The purpose of this article is to report our experience with recruitment and retention for a randomized trial of an online educational program to prepare oncology nurses to discuss oncology clinical trials with patients.

METHODS

The study population included currently employed oncology nurses with direct patient interaction. There were three phases of this study: (1) qualitative interviews, (2) a pilot test, and (3) the randomized trial. Phase 3 was rolled out in five waves of recruitment. The distinct phases of the study-and the gradual roll out of recruitment during Phase 3-allowed us to test and refine our recruitment and retention methods for the randomized trial. Upon analysis of our response rate and attrition after the first wave of recruitment in Phase 3, we made several changes to improve recruitment and retention, including adding incentives, shortening the survey, and increasing the number of reminders to complete the program.

RESULTS

The response rate was higher when we used both e-mail and U.S. postal mail solicitations. After the first wave of recruitment in the final phase, changes in our strategies did not increase our overall response rate significantly; however, the rate of attrition following baseline declined.

DISCUSSION

Recruitment planning is an important component of successful clinical research. The use of the Internet for both recruitment of subjects and testing of interventions remains a cost-effective and potentially high yield methodology. Our research demonstrated several successful approaches to yield increased participation and retention of subjects, including seeking formal relationships with professional organizations as sponsors or supporters, providing meaningful incentives to participants, keeping surveys or questionnaires as short as possible, and planning multiple follow-up contacts from the outset.

Total caseload of a colorectal surgical unit: baseline measurement and identification of areas for efficiency gains

PURPOSE

Resource limitations are a concern in most modern public hospital systems. The aim of this study is to prospectively quantify the total caseload of a tertiary colorectal surgery unit to identify areas of redundancy.

METHODS

Data was collected prospectively at all points of clinical care (outpatient clinic, inpatient referrals, operating theatre and endoscopy) between March 2014 and March 2015 using specifically designed templates. The final data was analysed using descriptive statistics.

RESULTS

During the study period, 4012 patient episodes were recorded: 2871 in outpatient clinic, 186 as emergency patient referrals, 541 at colonoscopy and 414 at surgery. The largest component of the caseload was made up primarily of colonoscopy results follow-up, protocol review for previous cancer or polyps and post-operative review. Sixty-eight percent of these episodes did not result in any active intervention such as further tests or surgery. Most new outpatient referrals were undifferentiated, with the most common indications being minor rectal bleeding, non-specific gastrointestinal symptoms, and minor non-bleeding anorectal problems. Of the new referrals, 56 % were booked for a colonoscopy, and only 13.3 % were booked directly for elective surgery.

CONCLUSION

A large component of the caseload of a tertiary colorectal surgery unit is made up of post-colonoscopy, post-operative, and surveillance protocol follow-up, with a significant proportion of patients not requiring any active intervention. The majority of new referrals are undifferentiated and result in a low rate of direct booking for operative intervention. Rationalisation of this resource using evidence-based methods could reduce redundancy, workload, and cost.

A Design Methodology for Medical Processes

BACKGROUND

Healthcare processes, especially those belonging to the clinical domain, are acknowledged as complex and characterized by the dynamic nature of the diagnosis, the variability of the decisions made by experts driven by their experiences, the local constraints, the patient's needs, the uncertainty of the patient's response, and the indeterminacy of patient's compliance to treatment. Also, the multiple actors involved in patient's care need clear and transparent communication to ensure care coordination.

OBJECTIVES

In this paper, we propose a methodology to model healthcare processes in order to break out complexity and provide transparency.

METHODS

The model is grounded on a set of requirements that make the healthcare domain unique with respect to other knowledge domains. The modeling methodology is based on three main phases: the study of the environmental context, the conceptual modeling, and the logical modeling.

RESULTS

The proposed methodology was validated by applying it to the case study of the rehabilitation process of stroke patients in the specific setting of a specialized rehabilitation center. The resulting model was used to define the specifications of a software artifact for the digital administration and collection of assessment tests that was also implemented.

CONCLUSIONS

Despite being only an example, our case study showed the ability of process modeling to answer the actual needs in healthcare practices. Independently from the medical domain in which the modeling effort is done, the proposed methodology is useful to create high-quality models, and to detect and take into account relevant and tricky situations that can occur during process execution.

Sistematização do conhecimento sobre as metodologias empregadas para o dimensionamento da força de trabalho em saúde

A força de trabalho em saúde representa um fator de grande importância nos sistemas de saúde, sendo imprescindível à promoção e ao avanço da área, relacionada quantitativa e qualitativamente aos resultados alcançados. Esta revisão sistemática visa à identificação na literatura de metodologias que, empregadas, resultem em dimensionamento eficaz da força de trabalho em saúde. Os resultados indicam a necessidade de complementação da avaliação, sendo indispensável a identificação de metodologias que resultem em dimensionamento mais eficaz da força de trabalho em saúde para subsidiar decisões gerenciais no sistema de saúde.

An Anticancer Drug Unit for the whole provincial oncologic network of Piacenza: improving safety and savings

In recent years, the expenditure for cancer care is increased largely due to the increase in cancer prevalence, demographic changes and incorporation into clinical practice of new and expensive drugs. For these reasons, solutions to contain costs are necessaries. The drugs-related expenditure is proportionally higher in oncology than in other medical specialties and overcomes staffing costs for outpatient care. The introduction of additional measures to contain and reduce expenditures such as waste reduction and human resources optimization is highly desirable. On April 2013, we started a day-to-day monitoring of the consumption of drugs and developed an internal protocol for waste minimization, consisting of five measures. A computerized research through Medline, Cancerlit and Embase was performed, applying the words drug waste, cost-containment, Anticancer Drug Unit and stability instructions. Articles and abstracts were also identified by back-referencing from other relevant papers. Selected for the present review were papers published in English without limit of year. The day-to-day monitoring of the consumption of drugs and the internal protocol for waste minimization were able to achieve a saving of <euro>15,700 every month. The projection of an annual cost-saving result of <euro>188.00 corresponds to a recovery of 4 % on the spending for oncologic drugs. Our data show that in a proper structure working according to the standards of quality, safety and sterility, preserving and reusing the drug waste within the limits imposed by the datasheets, it is possible to achieve a cost-containment policy and produce durable benefits.

Health information technology in oncology practice: a literature review

The adoption and implementation of information technology are dramatically remodeling healthcare services all over the world, resulting in an unstoppable and sometimes overwhelming process. After the introduction of the main elements of electronic health records and a description of what every cancer-care professional should be familiar with, we present a narrative review focusing on the current use of computerized clinical information and decision systems in oncology practice. Following a detailed analysis of the many coveted goals that oncologists have reached while embracing informatics progress, the authors suggest how to overcome the main obstacles for a complete physicians' engagement and for a full information technology adoption, and try to forecast what the future holds.

Clinical and organizational issues in the management of surviving breast and colorectal cancer patients: attitudes and feelings of medical oncologists

Background

The fast growing demand and the shortage of resources are pushing toward more efficient models of survivorship care delivery. The Associazione Italiana di Oncologia Medica (AIOM) established an interdisciplinary working group with the purpose of promoting organizational improvements at the national level. A survey aimed at assessing attitudes and feelings of oncologists was considered preliminary to further initiatives.

Methods

A 25-item questionnaire, sent to the mailing list of the Society, explored the following issues on the practice of breast and colorectal cancer patients' follow up: 1) organization; 2) clinical features; 3) feelings about the different meanings of follow-up.

Results

Ninety-one oncologists of 160 institutions (57%) answered to the questionnaire. Although follow up is considered a distinct oncological activity in 68%, a fully shared organization between specialists is not common and communications with Primary Care Physicians are not structured in the majority of the cases. Fifty-five and 30% of the oncologists follow breast and colorectal cancer patients indefinitely. In case of discharge a survivorship care plan is delivered in only 9%. The majority of respondents do not hold a role of follow up in mortality reduction.

Conclusions

Although survivorship care represents a significant part of the oncologists' workload, an “oncology-centered” model is largely adopted and established care pathways are still incomplete. Survivorship care needs to be put at the center of an educational policy and of a widespread organizational effort, directed at improving appropriateness and quality.

Drug waste minimization as an effective strategy of cost-containment in oncology

Background

Sustainability of cancer care is a crucial issue for health care systems worldwide, even more during a time of economic recession. Low-cost measures are highly desirable to contain and reduce expenditures without impairing the quality of care. In this paper we aim to demonstrate the efficacy of drug waste minimization in reducing drug-related costs and its importance as a structural measure in health care management.

Methods

We first recorded intravenous cancer drugs prescription and amount of drug waste at the Oncology Department of Udine, Italy. Than we developed and applied a protocol for drug waste minimization based on per-pathology/per-drug scheduling of chemotherapies and pre-planned rounding of dosages.

Results

Before the protocol, drug wastage accounted for 8,3% of the Department annual drug expenditure. Over 70% of these costs were attributable to six drugs (cetuximab, docetaxel, gemcitabine, oxaliplatin, pemetrexed and trastuzumab) that we named ‘hot drugs’. Since the protocol introduction, we observed a 45% reduction in the drug waste expenditure. This benefit was confirmed in the following years and drug waste minimazion was able to limit the impact of new pricely drugs on the Department expenditures.

Conclusions

Facing current budgetary constraints, the application of a drug waste minimization model is effective in drug cost containment and may produce durable benefits.

Lost in transition? Thoughts on retirement--"will you still need me, will you still feed me, when i'm sixty-four?"

Oncologists should plan for a future beyond full-time oncology, but there is little practical guidance for a successful transition into retirement. This paper provides strategies for various aspects of retirement planning and transitioning. More prospective information is needed.