Measurement of quality of care for adjuvant chemotherapy of colorectal cancer

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Background: Although adjuvant chemotherapy (CT) is a crucial component of the therapy for stage III colon cancer and stage II and III rectal cancer patients, little is known about how best to measure whether quality care is being delivered. We sought to provide policy-makers and stake-holders with an inventory of the available measures and their usefulness. Methods: The MEDLINE and Cochrane databases were searched for all publications which might contain quality measures (QMs) pertaining to the diagnosis and treatment of patients with colorectal cancer (CRC). Our analysis was confined to QMs pertaining to adjuvant CT for CRC, based on US data, and published after 1990. Identified QMs were quantitatively rated based on the concepts of importance/usability, scientific acceptability, and validity or how well they had been tested. Results: 3,429 abstracts were reviewed, of which 843 articles underwent full text evaluation. Ultimately 74 articles met the established inclusion criteria for containing QMs, 32 of which pertained to adjuvant CT. These 32 articles contained 10 QMs, 8 of which had major flaws limiting their applicability. The two most ideal measures are presented in the table . Among the reasons some measures did not rate highly was the failure to utilize standard staging definitions or reliance on administrative inpatient databases, which do not account for chemotherapy administered on an out-patient basis. Conclusions: Very few measures of the quality of adjuvant CT for CRC have been published to date and fewer rate highly with regard to the concepts of importance/usability, scientific acceptability, and validity. Future research should focus on refining existing QMs and on developing new QMs which target important leverage points with respect to the provision of adjuvant therapy for CRC.

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An audit of pre-operative skin preparative methods

INTRODUCTION

A study into how pre-operative skin preparation varies between surgical units and surgeons.

MATERIALS AND METHODS

A postal audit of general, vascular and thoracic surgeons in Northern Ireland was conducted together with a literature review to establish best practice.

RESULTS

Overall, 73 surgeons were contacted, and 63 (86.3%) responded. There was marked variation in shaving of the operative site. A wide range of solutions was used, and 14 different sequences were employed. All surgeons used a swab or sponge to apply the solutions. Several drying methods were employed.

CONCLUSIONS

There is variation in the method of skin preparation employed between surgical units and surgeons. There is limited evidence-based research on this topic. Recommendations are made as to best practice.

The use of multiattribute decision models in evaluating triptan treatment options in migraine

BACKGROUND

The physician treating patients with migraine is now able to choose from among seven triptans-almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan and zolmitriptan. These differ, to greater or lesser degrees, on a range of clinical attributes important for treatment selection.

OBJECTIVE

To outline the basic principles of Multiattribute Decision Making (MADM) and describe how one such method-TOPSIS (Technique for Order Preference by Similarity to the Ideal Solution)-can be applied to evaluate the currently available triptans.

METHODS

In an example application, summary data from a recent meta-analysis of 53 published and unpublished placebo-controlled trials of the oral triptans were combined in TOPSIS models with computer-generated attribute importance weights representing the entire range of possible values, That is, the relative performance of the triptans was explored across all logically possible combinations of relative importance of the treatment attributes available from the meta-analysis, and uncertainty was assessed based on the confidence intervals from the meta-analysis.

RESULTS

When compared across the entire range of values for relative attribute importance, almotriptan, eletriptan and rizatriptan were more similar to a hypothetical ideal triptan and were more likely to appear in the top three closest to the hypothetical ideal, than were naratriptan, sumatriptan, and zolmitriptan.

CONCLUSION

Using the TOPSIS model, almotriptan, eletriptan and rizatriptan were more likely to appear in the top three closest to the hypothetical ideal triptan.

How treatment priorities influence triptan preferences in clinical practice: perspectives of migraine sufferers, neurologists, and primary care physicians

BACKGROUND

In treating migraine sufferers, physicians can choose from among seven triptans with different attributes.

OBJECTIVE

To develop a system for selecting an oral triptan based on treatment priorities of migraine sufferers, neurologists, and primary care physicians (PCPs) in the United States, and evidence-based performance of triptans in clinical trials.

METHODS

The TRIPSTAR project combines data on the treatment preferences of migraineurs and physicians with results from a meta-analysis of individual triptans, which evaluated their effectiveness on various clinical endpoints. Telephone interviews with migraine sufferers, neurol ogists, and PCPs were conducted to elicit individual views on the relative importance of a prespecified set of acute treatment outcomes. Four hundred and fifteen migraine sufferers, both triptan-experienced and triptan-naive, were interviewed. Also, 200 board-certified neurologists and 200 PCPs provided information on migraine patients from their clinical practice. A multiattribute decision model for selecting an oral triptan was constructed using attribute importance weights collected at telephone interview and the meta-analysis data, which were drawn from 53 clinical trials of 6 oral triptans.

RESULTS

Efficacy attributes were rated significantly more important than tolerability or consistency in selecting an oral triptan, according to migraine sufferers and physicians. Freedom from cardiovascular adverse events was the most important tolerability attribute, according to migraine sufferers and physicians alike. Pain free at 1 h was the most important lower-level efficacy attribute for migraine sufferers, while sustained pain free was most important for physicians. When weighted treatment attributes were combined with meta-analysis data in a multi-attribute decision model, almotriptan 12.5 mg, eletriptan 80 mg, and rizatriptan 10 mg were significantly closer to the hypothetical ideal triptan than was suma triptan 100 mg. Triptans selected by the model were generally closer to the patient-specific ideal triptan than were the triptans prescribed by physicians.

CONCLUSIONS

Almotriptan, eletriptan, and rizatriptan were the three triptans closest to the ideal, from the perspectives of migraine sufferers, PCPs, and neurologists alike. The TRIPSTAR model may be a potentially useful decision-support tool to help physicians select the triptan most likely to produce a successful outcome in migraine sufferers.

Cost-effective models for flutamide for prostate carcinoma patients: are they helpful to policy makers?

BACKGROUND

More than 50,000 male patients received hormonal therapy for metastatic prostate carcinoma in 1995. Nonsteroidal antiandrogens, such as flutamide, when used in conjunction with castration, are effective in prolonging the time to progression of disease and survival. Only one-third of newly diagnosed patients with metastatic prostate carcinoma receive flutamide. Physicians may be reluctant to prescribe flutamide because of quality of life, toxicity, and cost considerations.

METHODS

Physician focus groups evaluated quality of life factors for metastatic prostate cancer.

RESULTS

Using quality of life estimates with the National Cancer Institute's (NCI) 0036 clinical trial results, our revised model of flutamide use predicted that, for minimal disease, survival increased by 4.33 quality adjusted months (QAMs) at an incremental cost of $25,000 per quality adjusted life year (QALY) saved and for severe disease, survival increased by 4.11 QAM at a cost of $18,000 per QALY saved. However, if quality of life estimates are used in conjunction with the Prostate Cancer Trialists' Collaborative Group (PCTCG) meta-analysis estimates, survival increased by 2.1 QAM at an incremental cost of $41,000 per QALY saved for persons with severe disease and increased by 2.6 QAM at an incremental cost of $53,700 per QALY saved for persons with minimal disease.

CONCLUSIONS

Using NCI 0036 trial data, flutamide has an incremental cost-effectiveness more favorable than most therapies, while estimates based on the PCTCG found a less favorable outcome for the drug. Concerns about out-of-pocket expenditures and efficacy limit flutamide utilization; quality of life considerations are less cogent.

Laparoscopic nephrectomy: initial experience and cost implications

OBJECTIVE

To assess the results and cost implications of laparoscopic nephrectomy.

PATIENTS AND METHODS

Ten patients underwent attempted laparoscopic nephrectomy and nephro-ureterectomy. The cost of the laparoscopic procedures was estimated to allow comparison with that of open surgery.

RESULTS

Two patients required conversion to an open procedure, one for a colonic tear, the other for irretrievable loss of pneumoperitoneum. The median operating time for successful cases was 3 h (range 2.5-4). The mean morphine equivalent of analgesia delivered per patient was 18 mg (range 10-28). There was no mortality. Post-operative complications consisted of one case of prolonged ileus and another of chest infection. The median hospital stay of successful cases was 5 days (range 4-17), and the mean time to return to normal activity was 4 weeks (range 3-6). The cost of the procedure using re-usable instruments was approximately 2000 pounds, comprising 100 pounds for equipment. 900 pounds theatre costs and 1000 pounds for hospital stay. Using disposable equipment adds up to 900 pounds to the cost. In comparison an open nephrectomy typically costs around 2300 pounds.

CONCLUSION

Laparoscopic nephrectomy is associated with lower analgesia requirements, shorter hospital stay and quicker return to work than equivalent open procedures. The cost, particularly when performed with re-usable instruments, is not prohibitive being comparable with that of open nephrectomy. With further experience it should become part of the armamentarium of urological surgeons.

Traumatic mitral valve rupture in a child

The case of a 6-year-old boy who ruptured his mitral valve after blunt chest trauma and who subsequently had successful mitral valve replacement with a size 25 St. Judge Medical prosthesis is reported. The diagnosis, investigation, and treatment of traumatic valvar rupture are discussed.