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Allende-Pérez S, García-Salamanca MF, Peña-Nieves A, Ramírez-Ibarguen A, Verástegui-Avilés E, Hernández-Lugo I, LeBlanc TW. Palliative Care in Patients With Hematological Malignancies. We Have a Long Way to Go…. Am J Hosp Palliat Care 2023; 40:1324-1330. [PMID: 36592366 DOI: 10.1177/10499091221149150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: Patients with hematological malignancies have significant and diverse palliative care needs but are not usually referred to specialist palliative care services in a timely manner, if at all. Objective: To identify the characteristics of patients with hematological malignancies referred to the palliative care service in a tertiary hospital in Mexico City. Patients: Retrospective study including consecutive patients with hematological malignancies referred to palliative care services at Mexico's National Cancer Institute. Results: Between 2011 and 2019, 5,017 patients with hematological malignancies were evaluated for first time at Mexico's National Cancer Institute. Of these, 9.1% (n = 457) were referred to palliative care. Most were male (53.4%), with a median age of 58 years. The most frequent diagnosis was non-Hodgkin lymphoma (54.9%). The primary indication for referral to palliative care was for cases wherein chemotherapy was no longer an option (disease refractory to treatment, 42.8%). The median time of referral to the palliative care service occurred 11.2 months after the first evaluation at the National Cancer Institute and death occurred on median 1.1 months after the first palliative care evaluation. Conclusion: Patients with hematological neoplasms are infrequently referred to Palliative Care at the Institute (9.1%). We found no clear referral criteria for Palliative Care referral and note that hematologists' optimism regarding a cure can delay referrals. Clearly, we have a long way to go in improving the number of patients referred, and we still saw frequent referrals near the end of life, but the high rate of outpatient referrals is encouraging.
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Affiliation(s)
| | | | | | | | | | | | - Thomas W LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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2
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Ham L, Slotman E, Burghout C, Raijmakers NJ, van de Poll-Franse LV, van Zuylen L, Fransen HP. Potentially inappropriate end-of-life care and its association with relatives' well-being: a systematic review. Support Care Cancer 2023; 31:731. [PMID: 38055062 DOI: 10.1007/s00520-023-08198-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 11/20/2023] [Indexed: 12/07/2023]
Abstract
PURPOSE Potentially inappropriate end-of-life cancer care (e.g., frequent hospital admission and emergency room visits in the last month of life) is known to be associated with a poorer quality of life of patients, but research on its association with the well-being of relatives is scarce. The aim of this systematic literature review was to evaluate the association between potentially inappropriate end-of-life cancer care and relatives' well-being. METHODS We conducted a systematic search and review, and reported according to the PRISMA guideline, on the association between potentially inappropriate end-of-life cancer care and well-being of relatives before and after the death of their loved one. Pubmed, PsycInfo, Embase, and CINAHL were searched for studies published from January 2000 to July 2022. Studies' quality was assessed using the Critical Appraisal Checklists from the Joanne Briggs Institute (JBI). RESULTS We identified eight studies including 10,062 relatives (59-79% female, mean age 46-61 years, 29-72% partner). Potentially inappropriate end-of-life cancer care was associated with poorer well-being of relatives including lower quality of life, higher burden of depressive symptoms, more regret, and more feelings of unpreparedness for the patient's death. CONCLUSION Potentially inappropriate cancer care at the end-of-life is associated with poorer well-being of relatives before and after the death of their loved one. This emphasizes the importance of avoiding potentially inappropriate end-of-life cancer care, as it is both associated with poorer outcomes for relatives and patients. However, the number of studies examining this association is small, and more research is needed in this area.
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Affiliation(s)
- Laurien Ham
- Department of Research & Development, The Netherlands Comprehensive Cancer Organization (IKNL), PO box 19079, 3501, DB, Utrecht, The Netherlands.
- Netherlands Association for Palliative Care (PZNL), Utrecht, The Netherlands.
| | - Ellis Slotman
- Department of Research & Development, The Netherlands Comprehensive Cancer Organization (IKNL), PO box 19079, 3501, DB, Utrecht, The Netherlands
| | - Carolien Burghout
- Department of Hemato-Oncology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
- Jeroen Bosch Academy Research, Jeroen Bosch Hospital, Den Bosch, The Netherlands
- Department of Tranzo, School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands
| | - Natasja Jh Raijmakers
- Department of Research & Development, The Netherlands Comprehensive Cancer Organization (IKNL), PO box 19079, 3501, DB, Utrecht, The Netherlands
| | - Lonneke V van de Poll-Franse
- Department of Research & Development, The Netherlands Comprehensive Cancer Organization (IKNL), PO box 19079, 3501, DB, Utrecht, The Netherlands
- Department of Medical and Clinical Psychology, CoRPS - Center for Research on Psychology in Somatic Diseases, Tilburg University, Tilburg, The Netherlands
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Amsterdam University Medical Centers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Heidi P Fransen
- Department of Research & Development, The Netherlands Comprehensive Cancer Organization (IKNL), PO box 19079, 3501, DB, Utrecht, The Netherlands
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3
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Shirane S, Michihata N, Yoshiuchi K, Ariyoshi K, Iwase S, Morita K, Matsui H, Fushimi K, Yasunaga H. Evaluation of quality indicators near death in older adult cancer decedents in Japan: A nationwide retrospective cohort study. Jpn J Clin Oncol 2021; 51:1643-1648. [PMID: 34530454 DOI: 10.1093/jjco/hyab145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/30/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES End-of-life cancer care is important; however, data on hospitalization and costs for older patients have been lacking. We aimed to examine quality indicators and costs for older patients in Japan. METHODS Using the Diagnosis Procedure Combination database, a national database of acute-care hospitals in Japan, we retrospectively collected data on cancer decedents aged ≥65 years. We evaluated the quality indicators (hospitalizations, length of stay in the hospital, emergency hospitalizations, emergency hospitalizations using an ambulance, intensive care unit [ICU] admissions, length of stay in the ICU, interval between last chemotherapy use and death, and chemotherapy within 14 days before death) and hospitalization costs at 30, 90 and 180 days before death. We compared the outcomes across age groups (65-74, 75-84 and ≥ 85 years). RESULTS Between January 2011 and March 2015, we identified 369 616 cancer decedents. From 180 to 30 days before death, there were increases in emergency hospitalizations, emergency hospitalizations using an ambulance, and the mean costs per hospital day. Overall, 16.7% of patients receiving chemotherapy last received this treatment on the day before death or the day of death. Costs decreased with increasing age. The group aged ≥85 years had the shortest hospital and ICU stays and the lowest multiple hospitalizations, ICU admissions, chemotherapy within 14 days before death, and costs. CONCLUSIONS Many older adult patients had emergency hospitalizations and received chemotherapy just prior to death, and there is room for improvement in appropriate end-of-life care. Oldest old patients consumed relatively few medical resources.
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Affiliation(s)
- Sachie Shirane
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiro Yoshiuchi
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Keisuke Ariyoshi
- Department of Data Management, Japanese Organisation for Research and Treatment of Cancer Data Center, Tokyo, Japan
| | - Satoru Iwase
- Department of Emergency and Palliative Medicine, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Kojiro Morita
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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4
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Chen L, Speers CH, Cheung WY, Spinelli JJ, Kennecke HF. Impact of new cancer therapies on outpatient treatment delivery for colorectal cancer: A population-based study. Int J Health Plann Manage 2021; 37:258-270. [PMID: 34545610 DOI: 10.1002/hpm.3308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 05/17/2021] [Accepted: 08/15/2021] [Indexed: 11/11/2022] Open
Abstract
We investigated the impact of new systemic therapies approved in Canada for colorectal cancer on the frequency, intensity and duration of oncology clinic and infusion visits over five treatment phases from diagnosis (P1, P3) to treatment (P2, P4) of primary and metastatic disease, respectively, and during the last 6 months of life (P5). In total, 15,157 adult patients with newly diagnosed colorectal cancer and referred between 2000 and 2012 to any cancer clinic in British Columbia, Canada, were included. Frequency, intensity and duration of medical oncology clinic visits (CVs), oncology infusions (OIs) and oncology prescriptions (OPs) were measured by treatment phase. Mean, total and adjusted total duration for CVs increased for P1-5. CVs increased in P1-5, and in P1-4 when adjusted by treatment length. Adjusted and unadjusted OIs decreased in P1 coinciding with the introduction of an oral treatment option, but increased in P2-5. Mean OI duration increased in P1-5, while total and adjusted total decreased in P1 and increased in P2-5. OPs increased in P2-4, but were unchanged in P1 and P5. Multi-fold increases in resources and time required per patient were also observed, which have significant implications for demand projections in cancer care planning and delivery. In conclusion, patients required more visits in almost all treatment phases, visits on average took longer and patients were in treatment for longer periods of time.
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Affiliation(s)
- Leo Chen
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Caroline H Speers
- Gastrointestinal Cancer Outcomes Unit, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Winson Y Cheung
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | - John J Spinelli
- Population Oncology, BC Cancer Research Centre, Vancouver, British Columbia, Canada
| | - Hagen F Kennecke
- Providence Cancer Institute Franz Clinic, Portland Providence Medical Center, Portland, Oregon, USA
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5
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Westgeest HM, Kuppen MCP, van den Eertwegh FAJM, van Oort IM, Coenen JLLM, van Moorselaar JRJA, Aben KKH, Bergman AM, Huinink DTB, van den Bosch J, Hendriks MP, Lampe MI, Lavalaye J, Mehra N, Smilde TJ, Somford RDM, Tick L, Weijl NI, van de Wouw YAJ, Gerritsen WR, Groot CAUD. High-Intensity Care in the End-of-Life Phase of Castration-Resistant Prostate Cancer Patients: Results from the Dutch CAPRI-Registry. J Palliat Med 2021; 24:1789-1797. [PMID: 34415798 DOI: 10.1089/jpm.2020.0800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Intensive end-of-life care (i.e., the overuse of treatments and hospital resources in the last months of life), is undesirable since it has a minimal clinical benefit with a substantial financial burden. The aim was to investigate the care in the last three months of life (end-of-life [EOL]) in castration-resistant prostate cancer (CRPC). Methods: Castration-resistant prostate cancer registry (CAPRI) is an investigator-initiated, observational multicenter cohort study in 20 hospitals retrospectively including patients diagnosed with CRPC between 2010 and 2016. High-intensity care was defined as the initiation of life-prolonging drugs (LPDs) in the last month, continuation of LPD in last 14 days, >1 admission, admission duration ≥14 days, and/or intensive care admission in last three months of life. Descriptive and binary logistic regression analyses were performed. Results: High-intensity care was experienced by 41% of 2429 patients in the EOL period. Multivariable analysis showed that age (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.97-0.99), performance status (OR 0.57, 95% CI 0.33-0.97), time from CRPC to EOL (OR 0.98, 95% CI 0.97-0.98), referral to a medical oncologist (OR 1.99, 95% CI 1.55-2.55), prior LPD treatment (>1 line OR 1.72, 95% CI 1.31-2.28), and opioid use (OR 1.45, 95% CI 1.08-1.95) were significantly associated with high-intensity care. Conclusions: High-intensity care in EOL is not easily justifiable due to high economic cost and little effect on life span, but further research is awaited to give insight in the effect on patients' and their caregivers' quality of life.
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Affiliation(s)
- Hans M Westgeest
- Department of Internal Medicine, Amphia Hospital, Breda, the Netherlands
| | - Malou C P Kuppen
- Institute for Medical Technology Assessment, Erasmus School of Health Policy and Management, Rotterdam, the Netherlands
| | - Fons A J M van den Eertwegh
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Inge M van Oort
- Department of Urology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | | | - Katja K H Aben
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands.,Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
| | - Andre M Bergman
- Division of Medical Oncology, the Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | | | - Joan van den Bosch
- Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
| | - Mathijs P Hendriks
- Department of Internal Medicine, Northwest Clinics, Alkmaar, the Netherlands
| | - Menuhin I Lampe
- Department of Urology, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Jules Lavalaye
- Department of Nuclear Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Niven Mehra
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Tineke J Smilde
- Department of Internal Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Rik D M Somford
- Department of Urology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Lidwine Tick
- Department of Internal Medicine, Maxima Medical Center, Eindhoven, the Netherlands
| | - Nir I Weijl
- Department of Internal Medicine, MCH-Bronovo Hospital, 's-Gravenhage, the Netherlands
| | - Yes A J van de Wouw
- Department of Internal Medicine, VieCuri Medical Center, Venlo, the Netherlands
| | - Winald R Gerritsen
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carin A Uyl-de Groot
- Institute for Medical Technology Assessment, Erasmus School of Health Policy and Management, Rotterdam, the Netherlands
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6
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Arbour C, Tremblay M, Ogez D, Martineau-Lessard C, Lavigne G, Rainville P. Feasibility and acceptability of hypnosis-derived communication administered by trained nurses to improve patient well-being during outpatient chemotherapy: a pilot-controlled trial. Support Care Cancer 2021; 30:765-773. [PMID: 34374847 PMCID: PMC8636401 DOI: 10.1007/s00520-021-06481-6] [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: 04/28/2021] [Accepted: 07/28/2021] [Indexed: 12/25/2022]
Abstract
Purpose This pilot-controlled trial aimed to examine the feasibility and acceptability of hypnosis-derived communication (HC) administered by trained nurses during outpatient chemotherapy to optimize symptom management and emotional support — two important aspects of patient well-being in oncology. Methods The trial was conducted in two outpatient oncology units: (1) intervention site (usual care with HC), and (2) control site (usual care). Nurses at the intervention site were invited to take part in an 8-h training in HC. Participants’ self-ratings of symptoms and emotional support were gathered at predetermined time points during three consecutive outpatient visits using the Edmonton Symptom Assessment Scale and the Emotional Support Scale. Results Forty-nine patients (24 in the intervention group, 25 in the control group) with different cancer types/stages were recruited over a period of 3 weeks and completed the study. All nurses (N = 10) at the intervention site volunteered to complete the training and were able to include HC into their chemotherapy protocols (about ± 5 min/intervention). Compared to usual care, patients exposed to HC showed a significant reduction in physical symptoms during chemotherapy. In contrast, perception of emotional support did not show any significant effect of the intervention. Participants exposed to HC report that the intervention helped them relax and connect on a more personal level with the nurse during chemotherapy infusion. Conclusions Our results suggest that HC is feasible, acceptable, and beneficial for symptom management during outpatient chemotherapy. While future studies are needed, hypnosis techniques could facilitate meaningful contacts between cancer patients and clinicians in oncology. Trial registration Clinical Trial Identifier: NCT04173195, first posted on November 19, 2019 Supplementary Information The online version contains supplementary material available at 10.1007/s00520-021-06481-6.
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Affiliation(s)
- Caroline Arbour
- Hôpital du Sacré-Cœur de Montréal, CIUSSS du Nord-de-L'Île-de-Montréal, 5400 Boul. Gouin Ouest, Room: E-1381, Montreal, QC, H4J 1C5, Canada. .,Faculty of Nursing, Université de Montréal, Montreal, QC, Canada.
| | - Marjorie Tremblay
- Hôpital de La Cité-de-La-Santé, CISSS de Laval, Laval, QC, Canada.,Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - David Ogez
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada.,Centre de Recherche de L'Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada
| | - Chloé Martineau-Lessard
- Hôpital du Sacré-Cœur de Montréal, CIUSSS du Nord-de-L'Île-de-Montréal, 5400 Boul. Gouin Ouest, Room: E-1381, Montreal, QC, H4J 1C5, Canada.,Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Gilles Lavigne
- Hôpital du Sacré-Cœur de Montréal, CIUSSS du Nord-de-L'Île-de-Montréal, 5400 Boul. Gouin Ouest, Room: E-1381, Montreal, QC, H4J 1C5, Canada.,Faculty of Dental Medicine, Université de Montréal, Montreal, QC, Canada
| | - Pierre Rainville
- Faculty of Dental Medicine, Université de Montréal, Montreal, QC, Canada.,Institut Universitaire de Gériatrie de Montréal, CIUSSS du Centre-Sud-de-L'Île-de-Montréal, Montreal, QC, Canada
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7
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Is SABR Cost-Effective in Oligometastatic Cancer? An Economic Analysis of the SABR-COMET Randomized Trial. Int J Radiat Oncol Biol Phys 2020; 109:1176-1184. [PMID: 33309977 DOI: 10.1016/j.ijrobp.2020.12.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/25/2020] [Accepted: 12/01/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE The phase 2 randomized study SABR-COMET demonstrated that in patients with controlled primary tumors and 1 to 5 oligometastatic lesions, SABR was associated with improved progression-free survival (PFS) compared with standard of care (SoC), but with higher costs and treatment-related toxicities. The aim of this study was to assess the cost-effectiveness of SABR versus SoC in this setting. METHODS AND MATERIALS A Markov model was constructed to perform a cost-utility analysis from the Canadian health care system perspective. Utility values and transition probabilities were derived from individual-level data from the SABR-COMET trial. One-way, 2-way, and probabilistic sensitivity analyses were performed. Costs were expressed in 2018 CAD. A separate analysis based on US payer's perspective was performed. An incremental cost-effectiveness ratio (ICER) at a willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY) was used. RESULTS In the base case scenario, SABR was cost-effective at an ICER of $37,157 per QALY gained. This finding was most sensitive to the number of metastatic lesions treated with SABR (ICER: $28,066 per QALY for 2, increasing to $64,429 per QALY for 5), difference in chemotherapy use (ICER: $27,173-$53,738 per QALY), and PFS hazard ratio (HR) between strategies (ICER: $31,548-$53,273 per QALY). Probabilistic sensitivity analysis revealed that SABR was cost-effective in 97% of all iterations. Two-way sensitivity analysis demonstrated a nonlinear relationship between the number of lesions and the PFS HR. To maintain cost-effectiveness for each additional metastasis, the HR must decrease by approximately 0.047. The US cost analysis yielded similar results, with an ICER of $54,564 (2018 USD per QALY) for SABR. CONCLUSIONS SABR is cost-effective for patients with 1 to 5 oligometastatic lesions compared with SoC.
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8
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Riaz F, Gan G, Li F, Davidoff AJ, Adelson KB, Presley CJ, Adamson BJ, Shaw P, Parikh RB, Mamtani R, Gross CP. Adoption of Immune Checkpoint Inhibitors and Patterns of Care at the End of Life. JCO Oncol Pract 2020; 16:e1355-e1370. [PMID: 32678688 PMCID: PMC8189605 DOI: 10.1200/op.20.00010] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2020] [Indexed: 01/12/2023] Open
Abstract
PURPOSE As immune checkpoint inhibitors (ICIs) have transformed the care of patients with cancer, it is unclear whether treatment at the end of life (EOL) has changed. Because aggressive therapy at the EOL is associated with increased costs and patient distress, we explored the association between the Food and Drug Administration (FDA) approvals of ICIs and treatment patterns at the EOL. METHODS We conducted a retrospective, observational study using patient-level data from a nationwide electronic health record-derived database. Patients had advanced melanoma, non-small-cell lung cancer (NSCLC; cancer types with an ICI indication), or microsatellite stable (MSS) colon cancer (a cancer type without an ICI indication) and died between 2013 and 2017. We calculated annual proportions of decedents who received systemic cancer therapy in the final 30 days of life, using logistic regression to model the association between the post-ICI FDA approval time and use of systemic therapy at the EOL, adjusting for patient characteristics. We assessed the use of chemotherapy or targeted/biologic therapies at the EOL, before and after FDA approval of ICIs using Pearson chi-square test. RESULTS There was an increase in use of EOL systemic cancer therapy in the post-ICI approval period for both melanoma (33.9% to 43.2%; P < .001) and NSCLC (37.4% to 40.3%; P < .001), with no significant change in use of systemic therapy in MSS colon cancer. After FDA approval of ICIs, patients with NSCLC and melanoma had a decrease in the use of chemotherapy, with a concomitant increase in use of ICIs at the EOL. CONCLUSION The adoption of ICIs was associated with a substantive increase in the use of systemic therapy at the EOL in melanoma and a smaller yet significant increase in NSCLC.
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Affiliation(s)
- Fauzia Riaz
- Cancer Outcomes Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT
- Stanford University School of Medicine, Stanford, CA
| | - Geliang Gan
- Yale Cancer Center, New Haven, CT
- Yale Center for Analytical Sciences, New Haven, CT
| | - Fangyong Li
- Yale Cancer Center, New Haven, CT
- Yale Center for Analytical Sciences, New Haven, CT
| | - Amy J. Davidoff
- Cancer Outcomes Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT
- Yale Cancer Center, New Haven, CT
| | - Kerin B. Adelson
- Cancer Outcomes Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT
- Yale Cancer Center, New Haven, CT
| | - Carolyn J. Presley
- Cancer Outcomes Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT
- The Ohio State University Comprehensive Cancer Center and The James Cancer Hospital/Solove Research Institute, Columbus, OH
| | | | | | - Ravi B. Parikh
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Ronac Mamtani
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Cary P. Gross
- Cancer Outcomes Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT
- Yale Cancer Center, New Haven, CT
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9
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End of life care for the most common women cancers in Taiwan. Public Health 2020; 186:119-124. [PMID: 32818724 DOI: 10.1016/j.puhe.2020.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 05/08/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Women with terminal cancer are assumed to choose hospice care over aggressive treatment at the end of life. With new chemotherapy and target therapy options, it becomes more difficult to decide between hospice care and aggressive management. It is also crucial to consider the cost increases leading to severe financial burdens on healthcare systems. To better understand treatment options at the individual level, this study set out to describe trends in end-of-life care for the four leading cancers in women in Taiwan. STUDY DESIGN This was a population-based retrospective cohort study. METHODS The data source was obtained between January 1, 2000, and December 31, 2013, from Taiwan's National Health Insurance Research Database. We identified 98,575 women with a diagnosis of breast (18,596), colorectal (23,734), liver and biliary (28,795) or lung (27,450) cancer who had died during the study period. Hospital data for services provided in the last 6 months of life, including hospice services and aggressive managements (chemotherapy, frequent hospitalisation, emergency room [ER] visits, intensive care unit [ICU] admission and endotracheal intubation), were collected. RESULTS Hospice utilisation increased over the study period, with 25.85%, 25.34%, 21.23% and 26.55% of female patients with breast, colorectal, liver and biliary, and lung cancer receiving hospice care, respectively. However, the number of women undergoing aggressive treatments in the last 6 months of life remained high, with the breast cancer group having the highest chemotherapy rate, the colorectal cancer group having frequent hospitalisation and the liver and biliary cancer group having frequent ER visits and ICU admissions. CONCLUSIONS Increasing hospice utilisation among women with the four most common cancers in Taiwan indicates that hospice services have gradually become well accepted over the past 13 years; however, the real focus is on the ineffective treatment preceding hospice care, and late referral was also a notable problem.
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10
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Rosella LC, Kornas K, Bornbaum C, Huang A, Watson T, Shuldiner J, Wodchis WP. Population-Based Estimates of Health Care Utilization and Expenditures by Adults During the Last 2 Years of Life in Canada's Single-Payer Health System. JAMA Netw Open 2020; 3:e201917. [PMID: 32236531 PMCID: PMC7113729 DOI: 10.1001/jamanetworkopen.2020.1917] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Measuring health care utilization and costs before death has the potential to initiate health care improvement. OBJECTIVE To examine population-level trends in health care utilization and expenditures in the 2 years before death in Canada's single-payer health system. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort included 966 436 deaths among adult residents of Ontario, Canada, from January 2005 to December 2015, linked to health administrative and census data. Data for deaths from 2005 to 2013 were analyzed from November 1, 2016, through January 31, 2017. Analyses were updated from May 1, 2019, to June 15, 2019, to include deaths from 2014 and 2015. EXPOSURES Sociodemographic exposures included age, sex, and neighborhood income quintiles, which were obtained by linking decedents' postal codes to census data. Aggregated Diagnosis Groups were used as a general health service morbidity-resource measure. MAIN OUTCOMES AND MEASURES Health care services accessed for the last 2 years of life, including acute hospitalization episodes of care, intensive care unit visits, and emergency department visits. Total health care costs were calculated using a person-centered costing approach. The association of area-level income with high resource use 1 year before death was analyzed with Poisson regression analysis, controlling for age, sex, and Aggregated Diagnosis Groups. RESULTS Among 966 436 decedents (483 038 [50.0%] men; mean [SD] age, 76.4 [14.96] years; 231 634 [24.0%] living in the lowest neighborhood income quintile), health care expenditures increased in the last 2 years of life during the study period (CAD$5.12 billion [US $3.83 billion] in 2005 vs CAD$7.84 billion [US $5.86 billion] in 2015). In the year before death, 758 770 decedents (78.5%) had at least 1 hospitalization episode of care, 266 987 (27.6%) had at least 1 intensive care unit admission, and 856 026 (88.6%) had at least 1 emergency department visit. Overall, deaths in hospital decreased from 37 984 (45.6%) in 2005 to 39 474 (41.5%) in 2015. Utilization in the last 2 years, 1 year, 180 days, and 30 days of life varied by resource utilization gradients. For example, the proportion of individuals visiting the emergency department was slightly higher among the top 5% of health care users compared with other utilization groups in the last 2 years of life (top 5%, 45 535 [94.2%]; top 6%-50%, 401 022 [92.2%]; bottom 50%, 409 469 [84.7%]) and 1 year of life (top 5%, 43 007 [89.0%]; top 6%-50%, 381 732 [87.8%]; bottom 50%, 380 859 [78.8%]); however, in the last 30 days of life, more than half of individuals in the top 6% to top 50% (223 262 [51.3%]) and bottom 50% (288 480 [59.7%]) visited an emergency department, compared with approximately one-third of individuals in the top 5% (16 916 [35.0%]). No meaningful associations were observed in high resource use between individuals in the highest income quintile compared with the lowest income quintile (rate ratio, 1.02; 95% CI, 0.99-1.05) after adjusting for relevant covariates. CONCLUSIONS AND RELEVANCE In this study, health care use and spending in the last 2 years of life in Ontario were high. These findings highlight a trend in hospital-centered care before death in a single-payer health system.
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Affiliation(s)
- Laura C. Rosella
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
| | - Kathy Kornas
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Catherine Bornbaum
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Health and Rehabilitation Sciences, Faculty of Health Sciences, Western University, London, Ontario, Canada
| | | | | | - Jennifer Shuldiner
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Walter P. Wodchis
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
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Kuo LC, Lee JJ, Cheung DST, Chen PJ, Lin CC. End-of-life care in cancer and dementia: a nationwide population-based study of palliative care policy changes. BMJ Support Palliat Care 2019; 12:bmjspcare-2019-001782. [PMID: 31530554 DOI: 10.1136/bmjspcare-2019-001782] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 08/13/2019] [Accepted: 08/21/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The National Health Insurance programme started providing coverage for inpatient care in palliative care (PC) units of acute care hospitals in 2000; however, initially, only PC provided to patients with terminal cancer was covered. A PC policy that enabled PC reimbursement for patients with dementia was implemented in 2009. However, the association of this PC policy with end-of-life care remains unclear. The study aims to compare the association of the PC policy with end-of-life care between patients with dementia and patients with cancer during the last 6 months of their lives. METHODS We analysed the claims data of 7396 patients dying with dementia (PDD) and 24 319 patients dying with cancer (PDC) during 1997-2013. RESULTS Among PDC, while the percentage of receiving PC increased from 3.6% in 1999 to 14.2% by the end of 2000 (adjusted OR (aOR)=4.07, 95% CI 2.70 to 6.13) and from 20.9% in 2010 to 41.0% in 2013 (aOR=1.40, 95% CI 1.33 to 1.47), vasopressor use decreased from 71.6% in 1999 to 35.5% in 2001 (aOR=0.90, 95% CI 0.82 to 0.98). Among PDD, PC use increased from 0.2% in 2009 to 4.9% in 2013 (aOR=2.05, 95% CI 1.60 to 2.63) and cardiopulmonary resuscitation use decreased from 17.6% in 2009 to 10.0% in 2013 (aOR=0.83, 95% CI 0.76 to 0.90). CONCLUSIONS Implementation of the PC policy in Taiwan was associated with improved PC utilisation among patients with cancer and dementia, which may reduce unnecessary medical care procedures.
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Affiliation(s)
- Lou-Ching Kuo
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Department of Nursing, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Jung Jae Lee
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Denise Shuk Ting Cheung
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Ping-Jen Chen
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City 807, Taiwan
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City 807, Taiwan
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London W1T 7NF, United Kingdom
| | - Chia-Chin Lin
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
- Alice Ho Miu Ling Nethersole Charity Foundation Professor in Nursing, Pokfulam, Hong Kong
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12
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Hu J, Aprikian AG, Vanhuyse M, Dragomir A. Cancer Drug Use in the Last Month of Life in Men With Castration-Resistant Prostate Cancer. J Oncol Pract 2019; 15:e510-e519. [PMID: 31107628 DOI: 10.1200/jop.18.00626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Several new drug therapies have been approved in CRPC in the past decade. However, little is known about their potential overuse at the end of life. Cancer therapy use at the end of life has been considered an indicator of overtreatment. The study objective was to describe CRPC drug use in the last month of life of CRPC patients in Quebec. PATIENTS AND METHODS Using administrative databases from the province of Quebec in Canada, we identified patients who received medical or surgical castration treatment, received one or more CRPC drugs (chemotherapy, abiraterone, or bone-targeted therapy), and died between 2001 and 2013. CRPC drug use in the last month of life was the primary outcome. RESULTS The cohort consisted of 1,148 patients with CRPC. A total of 316 men (27.5%) received a CRPC drug in the last month of life. For those who received chemotherapy, abiraterone, and bone-targeted therapy, 10.2%, 27.8%, and 31.8% received them in the last month of life, respectively. In multivariable analyses, age older than 75 years (odds ratio [OR], 0.75; 95% CI, 0.57 to 0.99), and prostate cancer diagnosis received less than 24 months earlier (OR, 0.43; 95% CI, 0.26 to 0.72) were associated with less CRPC drug use. Relative to dying between 2005 and 2011, dying between 2012 and 2013 (OR 1.60; 95% CI, 1.18 to 2.18) was associated with greater CRPC drug use. CONCLUSION More than one quarter of patients received CRPC drug therapies in the last month of life. Persistent chemotherapy, abiraterone, bone-targeted therapies, and medical castration drugs in the last month of life may be an indicator of inappropriate and expensive end-of-life care.
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Affiliation(s)
- Jason Hu
- 1 McGill University, Montreal, Quebec, Canada
| | - Armen G Aprikian
- 1 McGill University, Montreal, Quebec, Canada.,2 McGill University Health Centre, Montreal, Quebec, Canada
| | - Marie Vanhuyse
- 1 McGill University, Montreal, Quebec, Canada.,2 McGill University Health Centre, Montreal, Quebec, Canada
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De Schreye R, Houttekier D, Deliens L, Cohen J. Developing indicators of appropriate and inappropriate end-of-life care in people with Alzheimer's disease, cancer or chronic obstructive pulmonary disease for population-level administrative databases: A RAND/UCLA appropriateness study. Palliat Med 2017; 31:932-945. [PMID: 28429629 DOI: 10.1177/0269216317705099] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND A substantial amount of aggressive life-prolonging treatments in the final stages of life has been reported for people with progressive life-shortening conditions. Monitoring appropriate and inappropriate end-of-life care is an important public health challenge and requires validated quality indicators. AIM To develop indicators of appropriate and inappropriate end-of-life care for people with cancer, chronic obstructive pulmonary disease or Alzheimer's disease, measurable with population-level administrative data. DESIGN modified RAND/UCLA appropriateness method. SETTING/PARTICIPANTS Potential indicators were identified by literature review and expert interviews and scored in a survey among three panels of experts (one for each disease group). Indicators for which no consensus was reached were taken into group discussions. Indicators with consensus among the experts were retained for the final quality indicator sets. RESULTS The final sets consist of 28 quality indicators for Alzheimer's disease, 26 quality indicators for cancer and 27 quality indicators for chronic obstructive pulmonary disease. The indicator sets measure aspects of aggressiveness of care, pain and symptom treatment, specialist palliative care, place of care and place of death and coordination and continuity of care. CONCLUSION We developed a comprehensive set of quality indicators of appropriate and inappropriate end-of-life care in people with Alzheimer's disease, cancer or chronic obstructive pulmonary disease, to be used in population-level research. Our focus on administrative healthcare databases limits us to treatment and medication, excluding other important quality aspects such as communication, which can be monitored using complementary approaches. Nevertheless, our sets will enable an efficient comparison of healthcare providers, regions and countries in terms of their performance on appropriateness of end-of-life care.
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Affiliation(s)
- Robrecht De Schreye
- 1 End-of-life Care Research Group, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Dirk Houttekier
- 1 End-of-life Care Research Group, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Luc Deliens
- 1 End-of-life Care Research Group, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,2 Department of Medical Oncology, Ghent University, Ghent, Belgium
| | - Joachim Cohen
- 1 End-of-life Care Research Group, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
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Margolis B, Chen L, Accordino MK, Clarke Hillyer G, Hou JY, Tergas AI, Burke WM, Neugut AI, Ananth CV, Hershman DL, Wright JD. Trends in end-of-life care and health care spending in women with uterine cancer. Am J Obstet Gynecol 2017; 217:434.e1-434.e10. [PMID: 28709581 DOI: 10.1016/j.ajog.2017.07.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 06/28/2017] [Accepted: 07/06/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND High-intensity care including hospitalizations, chemotherapy, and other interventions at the end of life is costly and often of little value for cancer patients. Little is known about patterns of end-of-life care and resource utilization for women with uterine cancer. OBJECTIVE We examined the costs and predictors of aggressive end-of-life care for women with uterine cancer. STUDY DESIGN In this observational cohort study the Surveillance, Epidemiology, and End Results-Medicare linked database was used to identify women age ≥65 years who died from uterine cancer from 2000 through 2011. Resource utilization in the last month of life including ≥2 hospital admissions, >1 emergency department visit, ≥1 intensive care unit admission, or use of chemotherapy in the last 14 days of life was examined. High-intensity care was defined as the occurrence of any of the above outcomes. Logistic regression models were developed to identify factors associated with high-intensity care. Total Medicare expenditures in the last month of life are reported. RESULTS Of the 5873 patients identified, the majority had stage IV cancer (30.2%), were white (79.9%), and had endometrioid tumors (47.6%). High-intensity care was rendered to 42.5% of women. During the last month of life, 15.0% had ≥2 hospital admissions, 9.0% had a hospitalization >14 days, 15.3% had >1 emergency department visits, 18.3% had an intensive care unit admission, and 6.6% received chemotherapy in the last 14 days of life. The percentage of women who received high-intensity care was stable over the study period. Characteristics of younger age, black race, higher number of comorbidities, stage IV disease, residence in the eastern United States, and more recent diagnosis were associated with high-intensity care. The median Medicare payment during the last month of life was $7645. Total per beneficiary Medicare payments remained stable from $9656 (interquartile range $3190-15,890) in 2000 to $9208 (interquartile range $3309-18,554) by 2011. The median health care expenditure was 4 times as high for those who received high-intensity care compared to those who did not (median $16,173 vs $4099). CONCLUSION Among women with uterine cancer, high-intensity care is common in the last month of life, associated with substantial monetary expenditures, and does not appear to be decreasing.
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De Schreye R, Smets T, Annemans L, Deliens L, Gielen B, De Gendt C, Cohen J. Applying Quality Indicators For Administrative Databases To Evaluate End-Of-Life Care For Cancer Patients In Belgium. Health Aff (Millwood) 2017; 36:1234-1243. [DOI: 10.1377/hlthaff.2017.0199] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Robrecht De Schreye
- Robrecht De Schreye ( ) is a doctoral researcher in the End-of-Life Care Research Group at the University of Brussels, in Belgium
| | - Tinne Smets
- Tinne Smets is a postdoctoral senior researcher in the End-of-Life Care Research Group at the University of Brussels and a postdoctoral senior researcher at Ghent University, in Belgium
| | - Lieven Annemans
- Lieven Annemans is a professor in the Department of Public Health at Ghent University
| | - Luc Deliens
- Luc Deliens is a professor in the End-of-Life Care Research Group at the University of Brussels and a professor in the Department of Medical Oncology at Ghent University
| | - Birgit Gielen
- Birgit Gielen is a program manager in the Intermutualistic Agency, in Brussels
| | - Cindy De Gendt
- Cindy De Gendt is a senior researcher in the Belgian Cancer Registry, in Brussels
| | - Joachim Cohen
- Joachim Cohen is a professor in the End-of-Life Care Research Group at the University of Brussels and at Ghent University
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16
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Farris M, McTyre ER, Cramer CK, Hughes R, Randolph DM, Ayala-Peacock DN, Bourland JD, Ruiz J, Watabe K, Laxton AW, Tatter SB, Zhou X, Chan MD. Brain Metastasis Velocity: A Novel Prognostic Metric Predictive of Overall Survival and Freedom From Whole-Brain Radiation Therapy After Distant Brain Failure Following Upfront Radiosurgery Alone. Int J Radiat Oncol Biol Phys 2017; 98:131-141. [DOI: 10.1016/j.ijrobp.2017.01.201] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 01/12/2017] [Accepted: 01/17/2017] [Indexed: 10/20/2022]
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17
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De Oliveira C, Pataky R, Bremner KE, Rangrej J, Chan KKW, Cheung WY, Hoch JS, Peacock S, Krahn MD. Estimating the Cost of Cancer Care in British Columbia and Ontario: A Canadian Inter-Provincial Comparison. Healthc Policy 2017; 12:95-108. [PMID: 28277207 PMCID: PMC5344366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Costing studies are useful to measure the economic burden of cancer. Comparing costs between healthcare systems can inform evaluation, development or modification of cancer care policies. OBJECTIVES To estimate and compare cancer costs in British Columbia and Ontario from the payers' perspectives. METHODS Using linked cancer registry and administrative data, and standardized costing methodology and analyses, we estimated costs for 21 cancer sites by phase of care to determine potential differences between provinces. RESULTS Overall, costs were higher in Ontario. Costs were highest in the initial post-diagnosis and pre-death phases and lowest in the pre-diagnosis and continuing phases, and generally higher for brain cancer and multiple myeloma, and lower for melanoma. Hospitalization was the major cost category. Costs for physician services and diagnostic tests differed the most between provinces. CONCLUSIONS The standardization of data and costing methodology is challenging, but it enables interprovincial and international comparative costing analyses.
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Affiliation(s)
- Claire De Oliveira
- Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre for Addiction and Mental Health, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - Reka Pataky
- Canadian Centre for Applied Research in Cancer Control, British Columbia Cancer Agency, Vancouver, BC
| | - Karen E Bremner
- University Health Network, Toronto Health Economics and Technology Assessment Collaborative, Toronto, ON
| | - Jagadish Rangrej
- Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto, ON
| | - Kelvin K W Chan
- Canadian Centre for Applied Research in Cancer Control, Cancer Care Ontario, Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON
| | | | - Jeffrey S Hoch
- Center for Healthcare Policy and Research, Public Health Sciences, University of California Davis, St. Michael's Hospital, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - Stuart Peacock
- Canadian Centre for Applied Research in Cancer Control, British Columbia Cancer Agency, School of Population and Public Health, University of British Columbia, Faculty of Health Sciences, Simon Fraser University, Vancouver, BC
| | - Murray D Krahn
- Toronto Health Economics and Technology Assessment Collaborative, Faculty of Pharmacy and Institute of Health Policy, Management and Evaluation, University of Toronto, University Health Network, Toronto, ON
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