Pattern of Care and Outcomes of Adolescent and Young Adults with Lymphoma Treated in the Rhône-Alpes Region

Background: Management of adolescent and young adults (AYAs) cancer is very heterogeneous. In the case of lymphomas, outcomes are mostly favorable but there is still room for improvement. Design: We retrospectively collected the pattern of care of all institutional 13- to 25-year-old AYAs patients with classical Hodgkin lymphoma (HL) or non-Hodgkin lymphoma (NHL) diagnosed in the Rhône-Alpes region between the years 2000 and 2005. Management, including adherence to Clinical Practice Guidelines (CPGs), and long-term survival were analyzed by comparing adult units (AU) and pediatric units (PU). Results: 278 patients were included: 198 treated for HL (median age of 19 years), 80 treated for NHL (median age of 20 years). Among them, 74% were managed in AU and 26% in PU. The median time between diagnosis and starting treatment was significantly lower in PU than in AU. Sixty-five patients (23%) were included in clinical trials, mostly in AU. Five-year overall survival was 96% for HL [14 deaths, median follow-up 91 months (9-180)] and 90% for NHL [nine deaths, median follow-up 80 months (3-180)]. Secondary cancers occurred for 2% (n = 3) of HL patients and for none in NHL. Other major late complications included cardiovascular accidents in two patients and fatal pulmonary fibrosis in one patient. Major differences in chemotherapy and radiotherapy use are emphasized. Global management conformed to CPGs by 56%. Conclusions: Important differences between adult and pediatric management were reported, without any impact on survival. A few patients can be included in clinical trials: Homogeneity in management could improve specific care for AYAs.

Multidisciplinary first-day consultation accelerates diagnostic procedures and throughput times of patients in a head-and-neck cancer care pathway, a mixed method study

BACKGROUND

Head and neck cancers are fast growing tumours that are complex to diagnose and treat. Multidisciplinary input into organization and logistics is critical to start treatment without delay. A multidisciplinary first-day consultation (MFDC) was introduced to reduce throughput times for patients suffering from head and neck cancer in the care pathway. In this mixed method study we evaluated the effects of introducing the MFDC on throughput times, number of patient hospital visits and compliance to the Dutch standard to start treatment within 30 calendar-days.

METHODS

Data regarding 'days needed for referral', 'days needed for diagnostic procedures', 'days to start first treatment', and 'number of hospital visits' (process indicators) were retrieved from the medical records and analysed before and after implementation of the MFDC (before implementation: 2007 (n = 21), and after 2008 (n = 20), 2010 (n = 24) and 2013 (n = 24)). We used semi-structured interviews with medical specialists to explore a sample of outliers.

RESULTS

Comparing 2007 and 2008 data (before and after MFDC implementation), days needed for diagnostic procedures and to start first treatment reduced with 8 days, the number of hospital visits reduced with 1.5 visit on average. The percentage of new patients treated within the Dutch standard of 30 calendar-days after intake increased from 52 to 83%. The reduction in days needed for diagnostic procedures was sustainable. Days needed to start treatment increased in 2013. Semi-structured interviews revealed that this delay could be attributed to new treatment modalities, patients needed more time to carefully consider their treatment options or professionals needed extra preparation time for organisation of more complex treatment due to early communication on diagnostic procedures to be performed.

CONCLUSIONS

A MFDC is efficient and benefits patients. We showed that the MFDC implementation in the care pathway had a positive effect on efficiency in the care pathway. As a consequence, the extra efforts of four specialist disciplines, a nurse practitioner, and a coordinating nurse seeing the patient together during intake, were justified. Start treatment times increased as a result of new treatment modalities that needed more time for preparation.

The Brazilian Oral Health Survey (SBBrasil 2010) workflow from the coordinators' perspective

Introduction:

Although the workflow of population health surveys may interfere with the quality of the information produced, this aspect has not been investigated in the context of oral health.

Objective:

To identify the perception of the Brazilian Oral Health Survey (SBBrasil 2010 Project) coordinators regarding the survey's workflow.

Methods:

Data was collected using an electronic questionnaire sent to the coordinators after the national survey was completed. The variables investigated were grouped into themes spanning the various stages of the survey.

Results:

The response rate was of 75.6% (n = 161). The majority of respondents worked as municipal coordinators in the survey (82.6%), were females (68%), worked as civil servants in the public health system (65.2%), and occupied managerial positions (75.8%). The reported positive aspects of the survey were: planning, training and calibration workshops; the logistic support provided by both the health system and the survey's coordination team; the positive relationship between staff members, as well as the survey's acceptance by respondents and health professionals. The financial assistance offered for transportation during the survey and issues related to the grants received by coordinators were seen as negative aspects to be overcome. Most of the respondents reported that the research experience was useful in qualifying staff services and showed interest in participating in future oral health surveys.

Conclusion:

The coordinators' perception regarding their workflow in the SBBrasil 2010 Project was mainly positive. The results may contribute to the improvement of future oral health surveys.

Quality assessment in intensive care units: proposal for a scoring system in terms of structure and process

OBJECTIVE

We present a score for assessing the quality of ICU care in terms of structure and process, based on bibliographic review, expert consultations, field test, analysis, and final consensus, and analyze its initial application in the field.

DESIGN AND SETTING

This feasibility and observational study was conducted within the framework of a French regional clinical research project (NosoQual); 40 ICUs were visited and assessed between November 2002 and March 2003 according to standardized procedures.

MEASUREMENTS AND RESULTS

The grid consisted of 95 variables. The overall score derived from seven independent quality dimensions: human resources, architecture, safety and environment, management of documentation, patient care management, risk management of infections and evaluation, and surveillance. The average level of achievement of the scores varied from 48% to 63% of theoretical maxima. Variability in the individual dimensional subscores was greater than that of the overall score (CV=15).

CONCLUSIONS

Evaluation this scoring system encounters the limitation of the absence of a "gold standard." However, this is counterbalanced by the rigorous design methodology, the characteristic strengths of the quality dimensions. The survey also highlights also feasibility and the potential interest for specific tools for the assessment of ICUs.

Persistence of medical change at implementation of clinical guidelines on medical practice: a controlled study in a cancer network

PURPOSE

A cancer network of general or private hospitals of a French region was started in 1995 for improving quality of care and rationalizing medical prescriptions. The impact of implementing a clinical practice guidelines (CPG) project assessed conformity with guidelines in medical practice; significant changes were observed within the network, whereas no changes were observed in a control region without cancer network. In the present study, we evaluated the persistence of conformity to guidelines through a new medical audit.

PATIENTS AND METHODS

In 1999, the hospitals of the previously compared experimental and control groups accepted to reassess the impact of CPG. A controlled transversal study was performed in the experimental group (cancer network) and in the control group (no regional cancer network). In 1996 (first audit) and in 1999 (present audit), all new patients with colon cancer (177 and 200 in experimental group and 118 and 100 in control group, respectively) and early breast cancer (444 and 381 in experimental group and 172 and 204 in control group, respectively) were selected.

RESULTS

In the experimental group, the compliance of medical decisions with CPG was significantly higher in 1999 than in 1996 for colon cancer (73%; 95% CI, 67% to 79% v 56%; 95% CI, 49% to 63%, respectively; P = .003) and similar for the two periods for breast cancer (36%; 95% CI, 31% to 41% v 40%; 95% CI, 35% to 44%, respectively; P = .24). In the control group, compliance was significantly higher in 1999 than in 1996 for colon cancer (67%; 95% CI, 58% to 76% v 38%; 95% CI, 29% to 47%, respectively; P < .001) and identical for the two periods for breast cancer (4%; 95% CI, 1% to 7% v 7%; 95% CI, 3% to 11%, respectively; P = .19).

CONCLUSION

The CPG program for cancer management produced persistent changes in medical practice in our cancer network in terms of conformity with CPG.

Development of an instrument to measure patient perception of the quality of nursing care

Although patient satisfaction has been given considerable attention in health care, analysis of the conceptual and measurement limitations of existing measures indicates that a more elemental approach to obtaining patients' perspectives is warranted. In this investigation we developed and evaluated the psychometric properties of an instrument designed to measure patients' perceptions of the degree to which their needs were met while hospitalized. This 15-item instrument, Patient Perception of Hospital Experience with Nursing (PPHEN), based on Swanson-Kauffman's framework of caring, is internally consistent and represents a single construct best described as feeling cared for. The relationship of PPHEN to other measures demonstrates concurrent validity; moreover, the scale is responsive to differences in care provided, as shown by differences in means for different hospitals. PPHEN offers a brief, theoretically oriented, internally consistent, and valid patient self-report measure of nursing care. It does not require patients to compare their expectations of care with the care received but only to evaluate whether their needs were met. It promises to be useful to clinical and health services researchers.

Contemporary challenges for hospital epidemiology

According to conventional wisdom, it is time for hospital epidemiologists to look beyond traditional infection control responsibilities and to shoulder an "expanded role," including quality assurance, risk management, and pharmacoepidemiology. Some see this as a matter of survival as the profession reacts to potent external forces that seek to curb the cost of health care while assuring quality service. Infection control specialists, it is argued, have the epidemiologic skills to measure adverse outcomes of hospitalization, adjust for confounding variables, and evaluate the impact of targeted interventions. Before embracing these new responsibilities, however, it should be noted that many hospital epidemiologists would require additional training in basic epidemiologic principles. Although hospital epidemiologists may seek a leadership role in hospital quality assurance and health policy research, they have generally not been innovators in these fields, even in some specific areas relevant to infection control. For example, while hospital epidemiologists have begun to consider severity of illness as a potential confounder in epidemiologic analyses, they have not participated in the development or validation of any of the most widely used indicators. For those hospital epidemiologists who wish to capitalize on their traditional background in infectious diseases, contemporary infection control provides numerous challenges. For example, the epidemiology of many common nosocomial infections, such as bacterial pneumonia in immunocompromised hosts, remains to be defined. Hospital epidemiologists need to incorporate a variety of sophisticated microbiologic methods into their practice to help them trace the spread of nosocomial pathogens. Finally, they should collaborate more closely with clinical and bench investigators in a number of areas, including microbial pathogenesis, immunology, and biotechnology.