A cost comparison study to review community versus acute hospital models of nursing care delivered to oncology patients

PURPOSE

Ireland's Sláintecare health plan is placing an increased focus on primary care. A community oncology nursing programme was developed to train community nurses to deliver care in the community. While the initial pilot was proven to be clinically safe, no cost evaluation was carried out. This study aims to compare the costs of providing cancer support services in a day-ward versus in the community.

METHODS

183 interventions (40 in day-ward and 143 in community) were timed and costed using healthcare professional salaries and the Human Capital method.

RESULTS

From the healthcare provider perspective, the day-ward was a significantly cheaper option by an average of €17.13 (95% CI €13.72 - €20.54, p < 0.001). From the societal perspective, the community option was cheaper by an average of €2.77 (95% CI -€3.02 - €8.55), although this was a non-significant finding. Sensitivity analyses indicate that the community service may be significantly cheaper from the societal perspective.

CONCLUSIONS

Given the demand for cost-viable options for primary care services, this programme may represent a national option for cancer care in Ireland when viewed from the societal perspective.

Seasonal Inactivated Influenza Vaccination in Oncology Settings

Aims The aims of this study were to establish the uptake rate of seasonal influenza vaccine amongst oncology healthcare workers (HCWs) during the 2016/17 influenza season and to ascertain which factors were associated with or predicted vaccination, along with determining if national guidance regarding influenza vaccination for cancer patients is implemented. Methods A national cross-sectional study was carried out on clinical staff working in oncology day wards. Results Vaccine uptake during the 2016/17 season among oncology day ward staff was 48%. Fear of vaccine side-effects, believing that if one is healthy, there is no need for vaccination, and doubt about vaccine effectiveness negatively predicted vaccination. Most staff (87.6%) recommend vaccination to some or all patients. Conclusion Every effort should be made to ensure HCWs are given the opportunity to get vaccinated, provided with evidence of vaccine effectiveness and safety and empowered to recommend influenza vaccination to their patients.

Delivering care to oncology patients in the community: an innovative integrated approach

A community oncology nursing programme was developed in Ireland between the hospital and community health services for patients receiving systemic cancer therapy, in response to a service need. A robust evaluation of the pilot programme was undertaken, which found that defined clinical procedures traditionally undertaken in hospitals were safely undertaken in the patient's home with no adverse effects. There was a dramatic decrease in hospital attendances for these defined clinical procedures, and hospital capacity was consequently freed up. Patients valued having aspects of their care delivered at home and reported that it improved their quality of life, including reduced hospital visits and travel time. Community nurses expanded their scope of practice and became partners with oncology day-ward nurses in caring for these patients. Community nurses developed the competence and confidence to safely deliver cancer care in the community. This initiative shows that defined elements of acute cancer care can be safely delivered in the community so long as the training and support are provided. The findings and recommendations of the evaluation resulted in university accreditation and approval for national roll-out of the programme. Integration of services between primary and secondary care is a key priority. This innovative programme is a good example of shared integrated care that benefits both patients and health-care providers.

Using a mixed methods research design to investigate complementary alternative medicine (CAM) use among women with breast cancer in Ireland

AIM

To investigate complementary and alternative medicine (CAM) use among women with breast cancer in Ireland using a mixed methods modified sequential explanatory design.

METHODS

Semi-structured interviews were conducted with oncology professionals (n = 20) and CAM practitioners (n = 20) and this was followed by a survey of 406 women with breast cancer using the 'Use of Complementary and Alternative Therapies Survey' questionnaire (UCATS) (Lengacher et al., 2003). Follow up interviews were subsequently undertaken with a subset of this survey sample (n = 31).

RESULTS

Over half of those surveyed (55.7%, n = 226) used some form of CAM since diagnosis. The most frequently used therapies were massage, herbal supplements (including herbs with oestrogenic properties), antioxidants, relaxation, counselling, health supplements, reflexology, reiki and support groups. Dietary interventions were used primarily to reduce symptoms and/or side effects while reduction of psychological stress was the primary reason for use of stress-reducing therapies. Most respondents reported that the CAM therapies they had used were helpful. The qualitative data elaborated on and provided clarification of the survey results.

CONCLUSIONS

Similar to international studies, CAM is popular among women with breast cancer in Ireland. As such, the challenge for Irish oncology professionals is to identify low risk CAM therapies that are likely to benefit patients while educating patients and themselves on therapies which may be of concern. This study clearly illustrates the benefits of using a mixed methods approach to enhance our understanding of a complex clinical issue and thus we recommend that this method should be the method of choice when planning health services research.

Peroxidative interaction of myoglobin and myosin

Met-myoglobin [Fe(III)] was found to induce myosin cross-linking in the presence of H2O2 [Bhoite-Solomon, V. & Shaklai, N. (1992) Biochem. Int. 26, 181-189]. To assess the relevance of these findings to cellular pathology, peroxidation of myosin was performed with physiological divalent iron [Fe(II)] myoglobins in the oxy and deoxy forms. Both myoglobin forms were capable of mediating cross-linking of myosin. Deoxymyoglobin reactivity was similar to that of met-myoglobin, but the reactivity of oxymyoglobin was retarded compared to deoxymyoglobin. Cross-linking of myosin occurred under a low flow rate of H2O2 (3 microM/min) and in the presence of excess oxymyoglobin over H2O2, known to diminish the steady state of the myoglobin active heme [ferryl, Fe(IV)]state. The adenosinetriphosphatase activity of myosin was reduced to about half due to cross-linking. Addition of myoglobin/H2O2 to high myosin concentrations (> = 20 microM) turned the solutions into gels, a phenomenon explained by the further formation of intermolecular super cross-links of soluble myosin. Thus, at cellular ionic strength in which myosin is insoluble, cross-linking of myosin could still be triggered by myoglobin and H2O2. Based on these data, it is suggested that myoglobin-induced cross-linking of myosin and the consequent loss of adenosinetriphosphatase activity may be involved in muscle malfunction under hypoxia when cellular peroxidants increase and the deoxymyoglobin form prevails.

The role of H2O2-generated myoglobin radical in crosslinking of myosin

The mechanism of myoglobin/H2O2 derived peroxidation of myosin was studied by comparing the catalytic activity of myoglobin and horseradish peroxidase using O-dianisidine, N-acetyl tyrosine and myosin as substrates. It was found that both hemoproteins induced myosin crosslinking and concomitant tyrosines oxidation to bityrosines, suggesting inter-molecular coupling of tyrosines in the crosslinking. The enzymatic activity of both hemoproteins on myosin was weak compared to small substrates. While horseradish peroxidase was much more active than myoglobin on small substrates, the reverse was true for myosin peroxidation. Since the suicidal interaction of myoglobin with H2O2 forms unstable tyrosine radicals, we suggest that the increased activity of myoglobin on myosin results from an efficient electron transfer between surface tyrosines of myosin and myoglobin but not horseradish peroxidase. These conclusions were supported by evidence that sperm whale myoglobin, which contains two active tyrosines--the heme-adjacent (tyrosine-103) and the surface (tyrosine-151), is more active as a mediator of myosin peroxidation than horse heart myoglobin which is devoid of the surface tyrosine.