Cost-Effectiveness of Hospice Palliative Care for Patients With Cancer and Family Caregivers: A Multicenter Study in Kazakhstan

OBJECTIVES

In Kazakhstan, palliative care is offered through hospices, cancer centers, general hospitals, and mobile teams to approximately 107 000 patients in need. As a country with a transitional economy and a newly implemented social healthcare insurance system, Kazakhstan seeks a cost-effective allocation of limited resources for end-of-life care. This study aimed to assess cost-effectiveness of hospice-based palliative care for patients with cancer compared with the current standard of care provided in cancer centers across the country and, thereby, provide a better understanding for policy making regarding palliative care.

METHODS

A total of 182 family caregivers were recruited, 104 from 3 hospices and 78 from 3 palliative care units of cancer centers. Patients' state of health and family caregivers' burden were assessed with the Palliative Outcome Scale and the Zarit Burden Interview. Direct medical and nonmedical costs and family caregivers' out-of-pocket expenses associated with palliative care were collected. One-way and probabilistic sensitivity analysis was conducted by generating 1000 resamples using bootstrapping with Monte-Carlo simulation.

RESULTS

After 14 days of inpatient palliative care, patients' mean Palliative Outcome Scale score was 2.5 points better in the hospice group than the cancer center group. Family caregiver burden was 4.5 points better in the hospice group. Mean treatment costs were $31 lower for the hospice group. There was a statistically significant correlation between the total cost of treatment and patients' quality of life (r = 0.58). Probabilistic sensitivity analysis showed that hospice-based care has better outcomes and lower costs than care provided in cancer centers in 80% of tested scenarios.

CONCLUSION

Hospice-based palliative care is cost-effective compared with the care provided in palliative units of cancer centers in resource-limited settings in Kazakhstan.

Predicting Openness of Communication in Families With Hereditary Breast and Ovarian Cancer Syndrome: Natural Language Processing Analysis

BACKGROUND

In health care research, patient-reported opinions are a critical element of personalized medicine and contribute to optimal health care delivery. The importance of integrating natural language processing (NLP) methods to extract patient-reported opinions has been gradually acknowledged over the past years. One form of NLP is sentiment analysis, which extracts and analyses information by detecting feelings (thoughts, emotions, attitudes, etc) behind words. Sentiment analysis has become particularly popular following the rise of digital interactions. However, NLP and sentiment analysis in the context of intrafamilial communication for genetic cancer risk is still unexplored. Due to privacy laws, intrafamilial communication is the main avenue to inform at-risk relatives about the pathogenic variant and the possibility of increased cancer risk.

OBJECTIVE

The study examined the role of sentiment in predicting openness of intrafamilial communication about genetic cancer risk associated with hereditary breast and ovarian cancer (HBOC) syndrome.

METHODS

We used narratives derived from 53 in-depth interviews with individuals from families that harbor pathogenic variants associated with HBOC: first, to quantify openness of communication about cancer risk, and second, to examine the role of sentiment in predicting openness of communication. The interviews were conducted between 2019 and 2021 in Switzerland and South Korea using the same interview guide. We used NLP to extract and quantify textual features to construct a handcrafted lexicon about interpersonal communication of genetic testing results and cancer risk associated with HBOC. Moreover, we examined the role of sentiment in predicting openness of communication using a stepwise linear regression model. To test model accuracy, we used a split-validation set. We measured the performance of the training and testing model using area under the curve, sensitivity, specificity, and root mean square error.

RESULTS

Higher "openness of communication" scores were associated with higher overall net sentiment score of the narrative, higher fear, being single, having nonacademic education, and higher informational support within the family. Our results demonstrate that NLP was highly effective in analyzing unstructured texts from individuals of different cultural and linguistic backgrounds and could also reliably predict a measure of "openness of communication" (area under the curve=0.72) in the context of genetic cancer risk associated with HBOC.

CONCLUSIONS

Our study showed that NLP can facilitate assessment of openness of communication in individuals carrying a pathogenic variant associated with HBOC. Findings provided promising evidence that various features from narratives such as sentiment and fear are important predictors of interpersonal communication and self-disclosure in this context. Our approach is promising and can be expanded in the field of personalized medicine and technology-mediated communication.

Cost-effectiveness of hospice-based palliative care in Kazakhstan

Background

According to the Quality of Death Index, Kazakhstan ranks 50th out of 80 countries assessed. Currently, some form of inpatient end-of life care in Kazakhstan is provided by only 9 hospices, palliative care units and mobile teams. In 2020, the total number of palliative care beds did not exceed 980 across the country, while around 135,000 patients need palliative care at any given time.

Objective: To assess the effectiveness and cost-effectiveness of hospice-based palliative care for cancer patients compared to usual hospital care in cancer centers across Kazakhstan from societal perspective.

Methods

A total of 182 family caregivers were recruited, 104 in a hospice group and 78 in a control (palliative units). Patients’ state of health and family caregivers’ burden been measured using Palliative Outcome Scale (POS) and Zarit Burden Inventory (ZBI) on 14th day of the inpatient palliative care. Direct and indirect medical costs as well as family caregivers’ out-of-pocket expenses associated with the care has been collected. The cost-effectiveness analysis was conducted by calculating the difference between mean cost of treatment, including OOPs, over 14 days of treatment. Uncertainty around the cost-effectiveness estimates was explored by generating 10,000 resamples using bootstrapping.

Results

At 14 days, patients’ mean quality of life was 2,4 points better (95% CI: 0,06 - 4,9) in the hospice group compared to the control. Family caregiver burden was 4,6 points better in the hospice group (95% CI: -0,26 - 9.3). Mean treatment costs, including direct medical costs and out-of-pocket expenditures over 14 days were $31 lower for the hospice group (95% CI: $29 - $32). There was a significant correlation between the total cost of treatment and patients’ quality of life (rxy = 0,58; p < 0,01). The cost-effectiveness plane graphically represents 10,000 replications, 85% of them showed that hospice care has better outcomes and lower costs than the control group.

Key messages

• Hospice-based palliative care is cost-effective compared to the care provided in palliative units of cancer centers.

• There is a significant correlation between patients’ quality of life and family caregivers’ burden.

Cost-effectiveness of DNA testing for Lynch syndrome for colorectal cancer patients in Switzerland

Purpose

To estimate the cost-effectiveness of genetic testing for Lynch syndrome among newly diagnosed patients with colorectal cancer and targeted testing for their relatives in Switzerland.

Methods

We integrated decision tree and Markov model to calculate incremental costs per quality adjusted life-year saved for universal genetic testing for Lynch syndrome relative to using preliminary tumor tests (immunohistochemistry or microsatellite instability) followed by DNA sequencing test for patients with colorectal cancer.

Results

The incremental cost-effectiveness ratio (ICER) of the proposed strategy using universal genetic testing for Lynch syndrome with systematic CASCADE testing of their relatives is CHF 65,058 per QALY saved, which is cost-effective in Swiss settings where cost-effectiveness threshold is CHF 100,000 per QALY saved. The gained utility is 361,358 QALYs saved. Sensitivity analysis demonstrated cost-effectiveness of the proposed strategies in most of the scenarios.

Conclusions

The overall effectiveness of the universal genetic testing is greatly dependent on willingness of patients and relatives to be tested and compliance with the increased surveillance. Therefore, close cooperation across different stakeholders such as family doctors, oncologists, genetic clinicians, and laboratories is crucial to encourage and educate patients about the importance of the LS screening.

Key messages

Universal genetic testing for Lynch syndrome for all patients with colorectal caner is cost-effective in Swiss settings. Close cooperation across all stakeholders such as family doctors, oncologists, genetic clinicians, and laboratories is crucial to encourage and educate patients about the importance of the LS testing.

An advanced practice nurse-led delirium consultation service reduces delirium severity and length of stay in orthopedic patients: A nonrandomized posttest only evaluation study

PURPOSE

Delirium is an acute neuropsychiatric disorder and is a common and serious complication during hospitalization for older people. This study evaluated the value of an advanced practice nurse (APN)-led delirium consultation service on patient outcomes DESIGN AND METHODS: This was a retrospective chart review of 137 patients over 65 years, hospitalized between 2012 and 2015 in a tertiary care setting in Switzerland, who underwent orthopedic surgery and experienced delirium.

FINDINGS

Of the 137 eligible patients, 53 received the delirium consultation service and 84 received the standard care. The group receiving "early" delirium consultation experienced significantly reduced delirium severity over the course of time and the shortest length of stay.

PRACTICE IMPLICATIONS

The APN-led delirium consultation service had a positive effect on patient outcomes.

Nursing genetics and genomics: The International Society of Nurses in Genetics (ISONG) survey

BACKGROUND

The International Society of Nursing in Genetics (ISONG) fosters scientific and professional development in the discovery, interpretation, and application of genomic information in nursing research, education, and clinical practice.

OBJECTIVES

Assess genomic-related activities of ISONG members in research, education and practice, and competencies to serve as global leaders in genomics.

DESIGN

Cross-sectional survey (21-items) assessing genomic-related training, knowledge, and practice.

SETTINGS

An email invitation included a link to the anonymous online survey.

PARTICIPANTS

All ISONG members (n = 350 globally) were invited to partake.

METHODS

Descriptive statistics and Wilcoxon Rank Sum Test for between-group comparisons.

RESULTS

Respondents (n = 231, 66%), were mostly Caucasian, female, with a master's degree or higher. Approximately 70% wanted to incorporate genomics in research, teaching, and practice. More than half reported high genomic competency, and over 95% reported that genomics is relevant the next 5 years.

CONCLUSIONS

Findings provide a foundation for developing additional educational programs for an international nursing workforce in genomics.

The Interdependence of Advanced Cancer Patients' and Their Family Caregivers' Mental Health, Physical Health, and Self-Efficacy over Time

BACKGROUND

The challenges of advanced cancer have health implications for patients and their family caregivers from diagnosis through end of life. The nature of the patient/caregiver experience suggests that their mental and physical health maybe interdependent, but limited empirical evidence exists.

PURPOSE

This study used social cognitive theory as a framework to investigate individual and interpersonal influences on patients' and their family caregivers' mental health, physical health, and self-efficacy as individuals to manage the challenges of advanced disease over time.

METHODS

Patients and caregivers (484 patient-caregiver dyads) completed surveys at baseline, 3 and 6 months. Longitudinal dyadic analysis techniques were used to examine (i)the influence that patients and caregivers had on their own mental health, physical health, and self-efficacy (actor effects)and (ii) the influence that they had on each other's health outcomes (partner effects). We also examined the influence of self-efficacy on mental and physical health over time.

RESULTS

Consistent with our hypotheses, each person's mental health, physical health, and self-efficacy had significant effects on their own outcomes over time (actor effects). Patients and caregivers influenced one another's mental and physical health (partner effects), but not their self-efficacy. In addition, patients and caregivers with higher self-efficacy had better mental health, and their partners had better physical health.

CONCLUSIONS

Patients' and caregivers' mental and physical health were interdependent. Each person's cancer-related self-efficacy influenced their own mental and physical health. However, a person's self-efficacy did not influence the other person's self-efficacy.

Use of Pharmacologic Interventions for Breast Cancer Risk Reduction: American Society of Clinical Oncology Clinical Practice Guideline

Purpose

To update the 2009 American Society of Clinical Oncology guideline on pharmacologic interventions for breast cancer (BC) risk reduction.

Methods

A systematic review of randomized controlled trials and meta-analyses published from June 2007 through June 2012 was completed using MEDLINE and Cochrane Collaboration Library. Primary outcome of interest was BC incidence (invasive and noninvasive). Secondary outcomes included BC mortality, adverse events, and net health benefits. Guideline recommendations were revised based on an Update Committee's review of the literature.

Results

Nineteen articles met the selection criteria. Six chemoprevention agents were identified: tamoxifen, raloxifene, arzoxifene, lasofoxifene, exemestane, and anastrozole.

Recommendations

In women at increased risk of BC age ≥ 35 years, tamoxifen (20 mg per day for 5 years) should be discussed as an option to reduce the risk of estrogen receptor (ER) –positive BC. In postmenopausal women, raloxifene (60 mg per day for 5 years) and exemestane (25 mg per day for 5 years) should also be discussed as options for BC risk reduction. Those at increased BC risk are defined as individuals with a 5-year projected absolute risk of BC ≥ 1.66% (based on the National Cancer Institute BC Risk Assessment Tool or an equivalent measure) or women diagnosed with lobular carcinoma in situ. Use of other selective ER modulators or other aromatase inhibitors to lower BC risk is not recommended outside of a clinical trial. Health care providers are encouraged to discuss the option of chemoprevention among women at increased BC risk. The discussion should include the specific risks and benefits associated with each chemopreventive agent.

Prospective Assessment of Fatigue and Health Status in Greek Patients With Breast Cancer Undergoing Adjuvant Radiotherapy

PURPOSE/OBJECTIVES

To describe fatigue in women with breast cancer undergoing radiotherapy and to explore the impact of fatigue on their health status.

DESIGN

Prospective, descriptive, repeated measures.

SETTING

A major oncology center, Saint Savvas Cancer Hospital, in Athens, Greece.

SAMPLE

Consecutive sample of 106 women (mean age = 55 + 12), with histologically confirmed diagnosis for stage I or II breast cancer who were receiving adjuvant radiotherapy for approximately six weeks.

METHODS

Data were collected with the Revised Piper Fatigue Scale (PFS) and the Short Form-36 (SF-36) Health Survey Scale in the first two days of radiotherapy (T0), during the third week (T1), and during the last week of treatment (T2).

MAIN RESEARCH VARIABLES

Fatigue, health status.

FINDINGS

Across-subjects analysis revealed that fatigue increased during radiotherapy in patients with breast cancer regardless of stage, type of surgery, or whether they received chemotherapy (p 0.05). Between-subject analysis revealed that no differences existed in the PFS between different groups (chemotherapy versus no chemotherapy, breast conservation versus mastectomy, stage I versus stage II) at each measurement point. A negative correlation was found between the subscales of the PFS and all of the subscales of the SF-36.

CONCLUSIONS

Fatigue intensity increased significantly during the course of radiotherapy, and patients experienced a significant deterioration in their overall health status.

IMPLICATIONS FOR NURSING

Findings contribute to the growing body of evidence regarding fatigue and its impact on health status in Greek patients with breast cancer and provide insights for effective nursing assessment, patient education, and symptom management.

Evaluation of a visit preparation intervention implemented in two rural, underserved counties of Northern California

OBJECTIVE

Evaluate satisfaction with visit preparation at three rural resource center sites.

METHODS

The resource centers sent eight employees and two volunteers for training at UCSF in Consultation Planning (CP). CP is a service to help patients make a list of questions before seeing their doctors. Researchers used multivariate ordered logistic regression analysis to investigate the variation in satisfaction among 99 CP Clients served by the resource centers in 2003.

RESULTS

Sixty-seven CP Clients who completed surveys were highly satisfied (mean=8.67, standard deviation (S.D.)=1.85, range=5-10). Variation in satisfaction was associated only with whether or not the CP Provider was a breast cancer survivor serving a breast patient (p=0.005). Satisfaction was not associated with CP Client demographics; type of upcoming medical visit; or CP Provider age, remuneration status, nursing background, and volume of CP Clients.

CONCLUSION

Community-based resource centers have implemented CP to the satisfaction of their clients. Further research should expand the delivery of CP to more underserved members of the community and evaluate its acceptability and impact. There may be a therapeutic alliance formed when survivors provide CP to newly diagnosed patients.

PRACTICE IMPLICATIONS

CP should be considered by patient support programs wishing to expand their client services to include visit preparation.

Culture as an influence on breast cancer screening and early detection

OBJECTIVES

To explore how culture may play a part in breast cancer screening, early detection, and efforts to decrease breast mortality.

DATA SOURCES

Journal articles published in the past 20 years on cultural aspects of cancer prevention and control.

CONCLUSIONS

Research seems directed more at discovering cultural differences than at identifying similarities on how culture influences breast cancer screening and early detection. The influences of poverty and lack of educational opportunities account for much of what is termed cultural difference.

IMPLICATIONS FOR NURSING PRACTICE

Improving practice through an informed understanding of culture calls for considerable self-education and a fundamental refinement of care delivery.