Economic evaluation of a randomized clinical trial of hospital versus telephone follow-up after treatment for breast cancer

BACKGROUND

This was an economic evaluation of hospital versus telephone follow-up by specialist nurses after treatment for breast cancer.

METHODS

A cost minimization analysis was carried out from a National Health Service (NHS) perspective using data from a trial in which 374 women were randomized to telephone or hospital follow-up. Primary analysis compared NHS resource use for routine follow-up over a mean of 24 months. Secondary analyses included patient and carer travel and productivity costs, and NHS and personal social services costs of care in patients with recurrent breast cancer.

RESULTS

Patients who had telephone follow-up had approximately 20 per cent more consultations (634 versus 524). The longer duration of telephone consultations and the frequent use of junior medical staff in hospital clinics resulted in higher routine costs for telephone follow-up (mean difference pound 55 (bias-corrected 95 per cent confidence interval (b.c.i.) pound 29 to pound 77)). There were no significant differences in the costs of treating recurrence, but patients who had hospital-based follow-up had significantly higher travel and productivity costs (mean difference pound 47 (95 per cent b.c.i. pound 40 to pound 55)).

CONCLUSION

Telephone follow-up for breast cancer may reduce the burden on busy hospital clinics but will not necessarily lead to cost or salary savings.

Can lay people deliver asthma self-management education as effectively as primary care based practice nurses?

OBJECTIVES

To determine whether well trained lay people could deliver asthma self-management education with comparable outcomes to that achieved by primary care based practice nurses.

DESIGN

Randomised equivalence trial.

SETTING

39 general practices in West London and North West England.

PARTICIPANTS

567 patients with asthma who were on regular maintenance therapy. 15 lay educators were recruited and trained to deliver asthma self-management education.

INTERVENTION

An initial consultation of up to 45 min offered either by a lay educator or a practice based primary care nurse, followed by a second shorter face to face consultation and telephone follow-up for 1 year.

MAIN OUTCOME MEASURES

Unscheduled need for healthcare.

SECONDARY OUTCOME MEASURES

Patient satisfaction and need for courses of oral steroids.

RESULTS

567 patients were randomised to care by a nurse (n = 287) or a lay educator (n = 280) and 146 and 171, respectively, attended the first face to face educational session. During the first two consultations, management changes were made in 35/146 patients seen by a practice nurse (24.0%) and in 56/171 patients (32.7%) seen by a lay educator. For 418/567 patients (73.7%), we have 1 year data on use of unscheduled healthcare. Under an intention to treat approach, 61/205 patients (29.8%) in the nurse led group required unscheduled care compared with 65/213 (30.5%) in the lay led group (90% CI for difference -8.1% to 6.6%; 95% CI for difference -9.5% to 8.0%). The 90% CI contained the predetermined equivalence region (-5% to +5%) giving an inconclusive result regarding the equivalence of the two approaches. Despite the fact that all patients had been prescribed regular maintenance therapy, 122/418 patients (29.2%) required courses of steroid tablets during the course of 1 year. Patient satisfaction following the initial face to face consultation was similar in both groups.

CONCLUSIONS

It is possible to recruit and train lay educators to deliver a discrete area of respiratory care, with comparable outcomes to those seen by nurses.

Supportive care in the cancer setting: rhetoric or reality?

BACKGROUND

Since 1995, UK cancer policy has been directed at organizational changes to secure improvements in treatment outcomes and quality of supportive care for cancer patients. The substantial increase in hospital-based specialist cancer nurses (SCNs) during this time suggests they have a major role to play in the delivery of supportive care.

AIM

To explore how SCNs implemented their role in the context of organizational change and newly-formed multidisciplinary teams.

METHODS

Twenty-nine SCNs participated in observation and/or interviews, resulting in 135 hours of observation and in-depth semi-structured interviews with 17 SCNs. Data were collected and analysed using a grounded theory approach.

RESULTS

The prominence of the treatment agenda--the process of investigating, diagnosing and treating cancer--presented the biggest challenge to the delivery of supportive care. The treatment agenda influenced how support was offered, determined professional boundaries and relegated support to a subordinate position in patient care.

CONCLUSIONS

Access to supportive care is a central tenet of current cancer policy and crucial to the philosophy of patient-centred care. While SCNs are essential to the delivery of supportive care, this study highlights the challenges they encounter in organizations which prioritise treatment and improvements to treatment outcomes.

Involvement in treatment decisions: what do adults with asthma want and what do they get? Results of a cross sectional survey

BACKGROUND

Current healthcare policy advocates patient participation in treatment decision making. However, in asthma there is little evidence regarding patients' views on such involvement. This study explored the preferred and perceived level of involvement in treatment decisions, rationales for role preference, perceived facilitators of/barriers to involvement, and the interrelationship of role preference and demographic variables in a sample of patients with asthma.

METHODS

A cross sectional survey was performed of 230 adults with clinician diagnosed asthma from 10 primary care sites and one specialist respiratory centre in north-west England. Preferred role in treatment decisions was assessed using the Control Preferences Scale.

RESULTS

Fifty five (23.9%) preferred an active role, 82 (35.7%) a collaborative role, and 93 (40.4%) a passive role; 19 (8.2%) perceived their role as active compared with 45 (19.6%) collaborative and 166 (72.2%) passive. Only 33.5% (n = 77) of respondents attained their most preferred role; 55.2% (n = 127) were less involved than they preferred. Patient related, professional related, and organisational factors, especially quality and duration of consultations, facilitated or hampered involvement. Role preferences were not strongly associated with demographic variables or asthma severity.

CONCLUSIONS

This study in patients with asthma highlights the fact that there is a need for professional and patient education regarding partnership working, skilful communication, and innovative approaches to service delivery.

The changing face of cancer care in the UK: can nurses help to structure new services?

The concept of the lead cancer nurse is relatively new; no models of practice are available. An evaluation of lead cancer nurses was undertaken to identify core elements of success associated with this role. A two-stage multiple case study was used. In stage one, information was collected about post holders, working contexts, strategic aims and evidence of achievements from lead nurses, lead clinicians and senior nurses. Stage two explored the processes that enhanced and inhibited development of the lead nurse role. Site-visits were made to 12 Macmillan lead cancer nurses throughout the UK. Detailed information from interviews, observations and documentary materials were analysed using a framework that emphasized four key areas: assessment of current service, promotion of evidence-based practice, contribution to strategic decision making and consumer perspectives.

RESULTS

Enhancing factors important to the lead cancer nurses were the ability to: utilize decision-making power, build alliances and accommodate to a changing environment. Factors found to hinder achievement were: major changes in service and policy, restricted resources and the cancer site-specific structure of health service provisions. Further and greater contributions to cancer care from lead nurses require influential partnerships within local health care organizations and wider networks.

Palliative care: community nurses' perceptions of quality

OBJECTIVES

To identify community nurses' perceptions of quality care provision for patients requiring palliative care.

DESIGN

Semi-structured interviews were conducted with community nurses working within the district nursing service. An adaptation of Flanagan's critical incident technique was employed to elicit factors associated with high or poor quality palliative care. Interviews were tape recorded and transcribed. Data were analysed using thematic content analysis, recurrent themes being agreed by the research team.

SETTING

One community healthcare trust.

SUBJECTS

62 members of the district nursing team (grades B-H).

RESULTS

Respondents recounted the context in which high quality palliative care could be provided, the actions required, and the indicators that suggested the desired level of care had been achieved. Key factors identified were: the early referral of patients to the district nursing service, family circumstances, the availability of time, the accessibility of services and equipment, and the relationship with other healthcare professionals and informal carers. There was a general view that a positive outcome had been achieved when patients retained control over their circumstances and died a peaceful death, in the place of their choice, supported by their family.

CONCLUSIONS

Community nurses were able to articulate clearly the essential components of high quality care. Whilst these factors do not represent a comprehensive list, they are put forward as a useful starting point for standard setting and subsequent audit.

Did Project 2000 nurse training change recruitment patterns or career expectations?

In the UK, Project 2000 nurse education, introduced over the last eight years, aimed to increase the professional status of nurses and enhance skills, focusing on wider community care. This paper reports some of the results from a research project conducted between 1994 and 1996, funded by the Department of Health (Project 2000 Fitness for Purpose 1996). It was hypothesized that the changes in Project 2000 training might attract those more academically qualified and lead to more rapid career progression. The results found in this study did not support either of these hypotheses and suggestions are made about the reasons for the negative findings.

Users' views on palliative care services: ethical implications

This article is based on the findings of a study that elicited the views of terminally ill patients (n = 15), their carers (n = 10) and bereaved carers (n = 19) on the palliative care services they received. It explores the range of ethical issues revealed by the data. Although the focus of the original study was on community services, the participants frequently commented on all aspects of their experience. They described some of its positive and negative aspects. Of concern was the reported lack of sensitivity to the role of the family among health professionals. The family, as carers, service users and advocates, represent a challenge to professional boundaries and the ethical norms of confidentiality and best interest. The accounts reveal the complexity of the ethical issues that characterize terminal care, issuing specific ethical challenges to nurses and other health professionals involved in this field.

An evaluation of information cards as a means of improving communication between hospital and primary care for women with breast cancer

This paper describes an intervention study aimed at improving communication between hospital services and the primary health care team. A series of information cards were developed by breast specialist secondary care professionals for members of the primary health care team. Women with breast cancer were involved in the communication pathway and were asked to take the information cards to their own general practitioner (GP) practice. It was envisaged that women would be more likely to utilize the primary health care team for information if they were aware that the primary health care team was in receipt of information specific to the treatment they had received. Women newly diagnosed with breast cancer were allocated to either an intervention (n=38) or non-intervention (n=38) group. Patient interviews were carried out around the time of diagnosis and at 4 months from diagnosis. Interviews were also carried out with 31 GPs to ascertain their views on the provision of information for women with breast cancer, and on the information cards if relevant. The study findings were interesting although not significant in terms of the direction anticipated. The cards did not impact on the utilization of the primary health care team and women in the intervention group were no more likely to utilize primary care sources of information than women in the non-intervention group. Factors such as the long-standing relationship women had with their GP, the perceived lack of specialist knowledge on the part of GPs and district nurses, and the women's perception that information seeking was not a tangible reason for primary care contact had an impact on information-seeking behaviour.

The development of a national guideline on the management of leg ulcers

This paper describes the development of an evidence-linked clinical guideline for the management of uncomplicated venous leg ulcers. Guidelines are developed to provide recommendations for clinical practice which are based on summaries of good quality research evidence. The aim of the guideline discussed in this article is to direct primary health care practitioners to the most effective method of assessment and treatment of venous leg ulcers and to discourage practices that do not have convincing or sufficient evidence of effectiveness. The three most important steps to the development of a valid clinical guideline are: basing recommendations on the best available evidence; explicit linkage between guideline recommendations and quality of evidence; and the involvement of a multidisciplinary group. The steps are discussed in relation to the development of the guideline alongside an introductory presentation on the role guidelines can play in improving practice. Issues arising from guideline development such as valid ways of obtaining patient input and lack of evidence are also discussed.

Readability of patient information booklets for women with breast cancer

Providing accurate information, in both verbal and written formats, is seen as an important component of patient care. For individuals diagnosed with cancer, acquiring information may be a particularly pertinent issue in terms of coping with the disease. Numerous information booklets are available for people with cancer which aim to provide information on various aspects of care and treatment. This British study examined the readability of 50 information booklets available to women with breast cancer using the SMOG and Flesch reading tests. Generally the information booklets were found to have a high reading age, arguably not suitable for the majority of the United Kingdom (UK) population. This study has implications for health care professionals who provide written information as a supplement or substitute for verbal information.

The experiences of mothers caring for a child with severe atopic eczema

Atopic eczema is a relatively common disease which frequently occurs during childhood. This paper reports the findings of a research study which explored the effects upon family life of caring for a child with severe atopic eczema. Seventy-seven accounts written by mothers of preschool children with this disease were analysed using qualitative latent content analysis. The focus of this paper is on the implications of the disease for the mothers' role and the additional work generated by the disease. The implications of these findings for nursing practice, in particular the work of health visitors and paediatric community nurses, is discussed. Throughout this paper the term 'nurse' is used to describe both nurses and health visitors.

Patients' views of nurse prescribing

In 1994 the law was changed to allow nurses to prescribe from a limited formulary. The Department of Health commissioned research to evaluate nurse prescribing in eight pilot sites in England. This article presents part of this research. In particular, it examines how patients perceived the role of nurses and health visitors as prescribers. The study involved interviewing patients seen by community nurses before and after the introduction of nurse prescribing. The advantages patients identified coincided with the anticipated benefits, while the disadvantages that had been anticipated before the study were not confirmed. Patients were positive about nurses as prescribers and in some instances preferred nurses to doctors.

The use of qualitative methods in the study of parents' experiences of care on a children's surgical ward

User satisfaction with the care of hospitalized children is examined in this paper. It is argued that parents are proxy consumers but that their status is conditional on the way in which they exercise choices. Parents' involvement in the care of their children means that the term 'user' is more appropriate than 'consumer'. Methodological problems in the assessment of user satisfaction are discussed. A study of the experiences of parents of 24 children discharged from a surgical ward of a children's hospital is described and the implications for the assessment of user satisfaction reviewed. The study demonstrates that qualitative methods have value in the assessment of user satisfaction with care. A particular strength of qualitative methods of inquiry is that limitations of users' choice in care can be assessed.

The effects of contraceptive education on method use at first intercourse

Despite long-standing public support for sex education in the schools, it has been difficult to show concrete effects of sex education on sexual and contraceptive behavior. Data from the 1988 National Survey of Family Growth indicate that exposure to a formal contraceptive education program increases the likelihood that a teenage woman will use a contraceptive method at first intercourse. According to the results of a multivariate analysis, the odds that a young woman will use any method and the odds that she will use a condom increase by about one-third following instruction about birth control; the effect on the likelihood of pill use, however, is nonsignificant. If contraceptive education occurs in the same year that a teenager becomes sexually active, the odds of any method use and of condom use are increased by 70-80%, and the odds of pill use are more than doubled. The results also suggest that with greater educational efforts, the proportion of teenagers who use condoms at first intercourse could increase from 52% to 59%, while the proportion using no method might decrease from 41% to 33%.

Attitudes and stereotypes: nurses' work with older people

The study reported here sought to describe the differences between nurses' attitudes towards work with older people in the collective sense and their attitudes towards the individuals with whom they work. A convenience sample of 136 community nurses was obtained. Data were collected by means of a questionnaire incorporating the report of two critical incidents--one of effective practice and one of ineffective practice with older people. In addition in-depth qualitative interviews were conducted with 22 respondents. The findings lead the authors to challenge the common assumption that an identified lack of desire in nurses to work with older people is due solely to negative attitudes which nurses hold towards older people themselves. The paper concludes that the high dependency levels of older people and structure of nursing work with older people in hospitals means that fewer nurses make this area a positive career choice.

Community nurse attitudes to the clinical nurse specialist

At a time of unprecedented change in community nursing, it is appropriate to revisit the role of specialist and generalist nurses in community nursing teams. The data presented here are from a study of 130 home visits of 16 district nurses; the methods of data collection were participant observation and in-depth interview. Findings reflect a climate in which a substantial proportion of the community nurses' traditional role has been redefined as being the work of social services carers. There is a desire to become more involved in each area of community nursing work as the management of pain, diabetes and stoma care which, although common everyday activities, have increasingly been taken on by the clinical nurse specialist.

The six o'clock shock

Elderly people object to the early morning routines forced upon them in hospital, report Karen Luker and Karen Waters, who describe research carried out in a rehabilitation unit.

Rethinking patient education

The aim of this paper is to critically examine and challenge some of the assumptions which underpin the research and non-research based literature on patient education. Doubts are expressed concerning the transferability of theories of adult learning to patient education; and concern is expressed over the imbalance in the literature where emphasis is placed on the psychological benefits of teaching, rather than physical outcomes. In the light of the available evidence which suggests that nurses are not 'good patient teachers' the case is made to support the suggestion that patient education should become the responsibility of specialist nurses. In addition, computer-assisted learning (CAL) is proffered as the solution to a number of the problems facing patient educators. CAL is seen as a means of empowering the patient, rather than the nurse to take control, and this is viewed as a positive move in the direction of self-care. The paper concludes by suggesting that CAL might be used with good effect by patients with particular learning difficulties; for example the blind or partially sighted, and people who are illiterate or have a low reading ability.

Contraceptive risk taking and abortion: results and implications of a San Francisco Bay Area study

A study of 500 abortion-seeking women in the San Francisco Bay area, in California, revealed that, although a majority of them had used contraceptives previously, only a minority had consistently used effective contraceptives. This paper presents a theory of contraceptive risk taking and analyzes the decision making process described by 50 of the women during in-depth interviews. The decision not to contracept is shown to be the result of a rational process of "cost accounting." To decrease the need for abortion, it is argued, programs that change attitudes toward sexual behavior and that give women increasing economic opportunities are needed in addition to programs that make contraceptives more available.