Cost-effectiveness of a short stay admission programme for breast cancer surgery

Patient preferences for breast cancer screening: a systematic review update to inform recommendations by the Canadian Task Force on Preventive Health Care

BACKGROUND

Different guideline panels, and individuals, may make different decisions based in part on their preferences. Preferences for or against an intervention are viewed as a consequence of the relative importance people place on the expected or experienced health outcomes it incurs. These findings can then be considered as patient input when balancing effect estimates on benefits and harms reported by empirical evidence on the clinical effectiveness of screening programs. This systematic review update examined the relative importance placed by patients on the potential benefits and harms of mammography-based breast cancer screening to inform an update to the 2018 Canadian Task Force on Preventive Health Care's guideline on screening.

METHODS

We screened all articles from our previous review (search December 2017) and updated our searches to June 19, 2023 in MEDLINE, PsycINFO, and CINAHL. We also screened grey literature, submissions by stakeholders, and reference lists. The target population was cisgender women and other adults assigned female at birth (including transgender men and nonbinary persons) aged ≥ 35 years and at average or moderately increased risk for breast cancer. Studies of patients with breast cancer were eligible for health-state utility data for relevant outcomes. We sought three types of data, directly through (i) disutilities of screening and curative treatment health states (measuring the impact of the outcome on one's health-related quality of life; utilities measured on a scale of 0 [death] to 1 [perfect health]), and (ii) other preference-based data, such as outcome trade-offs, and indirectly through (iii) the relative importance of benefits versus harms inferred from attitudes, intentions, and behaviors towards screening among patients provided with estimates of the magnitudes of benefit(s) and harms(s). For screening, we used machine learning as one of the reviewers after at least 50% of studies had been reviewed in duplicate by humans; full-text selection used independent review by two humans. Data extraction and risk of bias assessments used a single reviewer with verification. Our main analysis for utilities used data from utility-based health-related quality of life tools (e.g., EQ-5D) in patients; a disutility value of about 0.04 can be considered a minimally important value for the Canadian public. When suitable, we pooled utilities and explored heterogeneity. Disutilities were calculated for screening health states and between different treatment states. Non-utility data were grouped into categories, based on outcomes compared (e.g. for trade-off data), participant age, and our judgements of the net benefit of screening portrayed by the studies. Thereafter, we compared and contrasted findings while considering sample sizes, risk of bias, subgroup findings and data on knowledge scores, and created summary statements for each data set. Certainty assessments followed GRADE guidance for patient preferences and used consensus among at least two reviewers.

FINDINGS

Eighty-two studies (38 on utilities) were included. The estimated disutilities were 0.07 for a positive screening result (moderate certainty), 0.03-0.04 for a false positive (FP; "additional testing" resolved as negative for cancer) (low certainty), and 0.08 for untreated screen-detected cancer (moderate certainty) or (low certainty) an interval cancer. At ≤12 months, disutilities of mastectomy (vs. breast-conserving therapy), chemotherapy (vs. none) (low certainty), and radiation therapy (vs. none) (moderate certainty) were 0.02-0.03, 0.02-0.04, and little-to-none, respectively, though in each case findings were somewhat limited in their applicability. Over the longer term, there was moderate certainty for little-to-no disutility from mastectomy versus breast-conserving surgery/lumpectomy with radiation and from radiation. There was moderate certainty that a majority (>50%) and possibly a large majority (>75%) of women probably accept up to six cases of overdiagnosis to prevent one breast-cancer death; there was some uncertainty because of an indication that overdiagnosis was not fully understood by participants in some cases. Low certainty evidence suggested that a large majority may accept that screening may reduce breast-cancer but not all-cause mortality, at least when presented with relatively high rates of breast-cancer mortality reductions (n = 2; 2 and 5 fewer per 1000 screened), and at least a majority accept that to prevent one breast-cancer death at least a few hundred patients will receive a FP result and 10-15 will have a FP resolved through biopsy. An upper limit for an acceptable number of FPs was not evaluated. When using data from studies assessing attitudes, intentions, and screening behaviors, across all age groups but most evident for women in their 40s, preferences reduced as the net benefit presented by study authors decreased in magnitude. In a relatively low net-benefit scenario, a majority of patients in their 40s may not weigh the benefits as greater than the harms from screening whereas for women in their 50s a large majority may prefer screening (low certainty evidence for both ages). There was moderate certainty that a large majority of women 50 years of age and 50 to 69 years of age, who have usually experienced screening, weigh the benefits as greater than the harms from screening in a high net-benefit scenario. A large majority of patients aged 70-71 years who have recently screened probably think the benefits outweigh the harms of continuing to screen. A majority of women in their mid-70s to early 80s may prefer to continue screening.

CONCLUSIONS

Evidence across a range of data sources on how informed patients value the potential outcomes from breast-cancer screening will be useful during decision-making for recommendations. The evidence suggests that all of the outcomes examined have importance to women of any age, that there is at least some and possibly substantial (among those in their 40s) variability across and within age groups about the acceptable magnitude of effects across outcomes, and that provision of easily understandable information on the likelihood of the outcomes may be necessary to enable informed decision making. Although studies came from a wide range of countries, there were limited data from Canada and about whether findings applied well across an ethnographically and socioeconomically diverse population.

SYSTEMATIC REVIEW REGISTRATION

Protocol available at Open Science Framework https://osf.io/xngsu/ .

A Systematic Literature Review of Health Utility Values in Breast Cancer

BACKGROUND

Health utility values (HUVs) are important inputs to the cost-utility analysis of breast cancer interventions.

PURPOSE

Provide a catalog of breast cancer-related published HUVs across different stages of breast cancer and treatment interventions.

DATA SOURCES

Systematic searches of MEDLINE, MEDLINE In-Process, EMBASE, Web of Science, CINAHL, PsycINFO, EconLit, and Cochrane databases (2005-2017).

STUDY SELECTION

Studies published in English that reported mean or median HUVs using direct or indirect methods of utility elicitation for breast cancer.

DATA EXTRACTION

Independent reviewers extracted data on a preestablished and piloted form; disagreements were resolved through discussion.

DATA ANALYSIS

Mixed-effects meta-regression using restricted maximum likelihood modeling was conducted for intervention type, stage of breast cancer, and typical clinical and treatment trajectory of breast cancer patients to assess the effect of study characteristics (i.e., sample size, utility elicitation method, and respondent type) on HUVs.

DATA SYNTHESIS

Seventy-nine studies were included in the review. Most articles (n = 52, 66%) derived HUVs using the EQ-5D. Patients with advanced-stage breast cancer (range, 0.08 to 0.82) reported lower HUVs as compared with patients with early-stage breast cancer (range, 0.58 to 0.99). The meta-regression analysis found that undergoing chemotherapy and surgery and radiation, being diagnosed with an advanced stage of breast cancer, and recurrent cancer were associated with lower HUVs. The members of the general public reported lower HUVs as compared with patients.

LIMITATIONS

There was considerable heterogeneity in the study population, health states assessed, and utility elicitation methods.

CONCLUSION

This review provides a catalog of published HUVs related to breast cancer. The substantial heterogeneity in the health utility studies makes it challenging for researchers to choose which HUVs to use in cost-utility analyses for breast cancer interventions.

Practical Guide to Implementation Science for Surgical Oncologists: Case Study of Breast Cancer Short Stay Program

BACKGROUND

Long lags exist in adoption and uptake of evidence-based interventions into real-world clinical practice based on oncology clinical trial results. Implementation science (IS) is a distinct field of health services research that aims to understand the barriers related to adoption of evidence-based guidelines and research in clinical practice.

METHODS

Use of IS study design, methods, and outcomes can be elusive to surgical oncologists despite the tremendous need for the application of IS to bridge the evidence-to-practice gap. This report describes key components of high-quality IS.

RESULTS

Herein, we illustrate how IS can be used in surgical oncology practice. Examples from implementation of the breast cancer Short Stay Program (SSP) in Netherlands is used to illustrate IS methods. Specific funding and training opportunities in implementation science are described in detail.

CONCLUSION

Use of IS in surgical oncology can help improve the uptake of evidence based medicine.

Same-Day Surgery for Mastectomy Patients in Alberta: A Perioperative Care Pathway and Quality Improvement Initiative

BACKGROUND

Same-day surgery (SDS) following mastectomy is safe and well accepted. Overnight admission in patients fit for discharge is an inefficient use of health resources. In response to a national review highlighting SDS following mastectomy at 1.4% in Alberta, a perioperative pathway was conceived.

METHODS

The pathway was implemented across Alberta at 13 hospitals beginning in 2016. A steering committee was assembled, and clinical and administrative leads at each site were identified. Opportunities along the patient care experience whereby action could be taken to promote uptake of SDS were identified. Provincially branded support materials including presentations, order sets, and standard operating procedures were developed. Nurse educators provided in-service teaching such as standardized drain care and discharge teaching. Educational booklets, group classes, and online resources were developed for patients and families. An audit of SDS rates, unscheduled return to the emergency department (ED), and readmission rates was reported to teams quarterly, allowing for iterative modifications. Patient-reported experience measures (PREMs) were collected.

RESULTS

SDS following mastectomy increased from 1.7 to 47.8%, releasing an estimated 831 bed days per year. No differences in unexpected return to the ED or readmission to hospital existed between SDS patients and those admitted overnight. A total of 102 patients completed the PREM survey, of whom 90% felt "excellent or good" with the plan to go home, how to care for themselves once home, and who to contact should issues arise.

CONCLUSIONS

Implementation of a provincial perioperative pathway improved uptake of SDS following mastectomy and demonstrated favorable PREMs.

Safety and feasibility of early postmastectomy discharge and home drain care in a low resource setting

BACKGROUND

Early postmastectomy discharge with a drain in place is standard practice in most developed countries. Its feasibility has not been evaluated in low resource settings like Nigeria.

METHODS

Consenting patients undergoing mastectomy were discharged on the third postoperative day and assessed as outpatients for wound complications as well as their experience at home. Wound outcomes were compared with patients who had traditional long stay.

RESULTS

Forty-five of the 58 patients who had a mastectomy during the study period participated in the early discharge program (77.6%). Of these, four patients (8.9%) had drain malfunction, seroma occurred in eight patients (17.8%), eight patients (17.8%) had wound infection, and six patients (13.3%) had flap necrosis. There was no readmission. Compared with long stay patients, postoperative stay was significantly shorter (3 vs 11 days; P < 0.01) with significant cost savings, while complication rates were not statistically different. All the patients in the early discharge group were confident operating their drains and preferred early discharge. Being around relatives, reduced cost, and fear of the hospital environment were common reasons cited for their preference.

CONCLUSION

Our results support the implementation of an early postmastectomy discharge program in a low resource setting.

Same-Day Major Breast Cancer Surgery is Safe: An Analysis of Short-Term Outcomes Using NSQIP Data

INTRODUCTION

Most patients undergoing significant breast cancer surgery stay in hospital postoperatively. We sought to determine whether there was a difference in complication rates among patients undergoing same-day surgery (SDS) versus overnight or inpatient stay.

METHODS

Analysis of the American College of Surgeons, National Surgical Quality Improvement Program participant user files was performed. Patients with breast cancer undergoing mastectomy and/or axillary lymph node dissection between 2005 and 2012 were examined (high-risk comorbidities and concurrent surgery were excluded). Thirty-day postoperative morbidity was analyzed. Multivariable regression was performed identifying independent predictors of complications.

RESULTS

The final population consisted of 40,575 patients; 8365 had SDS, 23,252 stayed overnight, and 8958 stayed in hospital longer postoperatively. Those admitted to hospital were older, more obese, had higher American Society of Anesthesiology (ASA) class, medical comorbidities, or had bilateral surgery. The overall 30-day morbidity was 4.7 %. On univariate analysis, patients undergoing SDS had significantly lower 30-day morbidity (2.4 %) compared with overnight (3.9 %) or inpatient stay (8.8 %) (p < 0.0001). After controlling for the above differences between groups, patients staying overnight had a higher odds of postoperative complications [1.37, 95 % confidence interval (CI) 1.16-1.63, p = 0.004] and inpatients had over twice the odds of postoperative complications (2.65, 95 % CI 2.21-3.18, p < 0.0001) compared with SDS patients.

CONCLUSION

This is the largest study examining the safety of SDS for breast cancer. Complication rates were significantly higher for patients admitted to hospital postoperatively, even after controlling for baseline differences. These data suggest that, with appropriate selection, it is safe to perform major breast cancer surgery on a same-day basis.

A stepped strategy that aims at the nationwide implementation of the Enhanced Recovery After Surgery programme in major gynaecological surgery: study protocol of a cluster randomised controlled trial

Background

Enhanced Recovery After Surgery (ERAS) programmes aim at an early recovery after surgical trauma and consequently at a reduced length of hospitalisation. This paper presents the protocol for a study that focuses on large-scale implementation of the ERAS programme in major gynaecological surgery in the Netherlands. The trial will evaluate effectiveness and costs of a stepped implementation approach that is characterised by tailoring the intensity of implementation activities to the needs of organisations and local barriers for change, in comparison with the generic breakthrough strategy that is usually applied in large-scale improvement projects in the Netherlands.

Methods

All Dutch hospitals authorised to perform major abdominal surgery in gynaecological oncology patients are eligible for inclusion in this cluster randomised controlled trial. The hospitals that already fully implemented the ERAS programme in their local perioperative management or those who predominantly admit gynaecological surgery patients to an external hospital replacement care facility will be excluded. Cluster randomisation will be applied at the hospital level and will be stratified based on tertiary status. Hospitals will be randomly assigned to the stepped implementation strategy or the breakthrough strategy. The control group will receive the traditional breakthrough strategy with three educational sessions and the use of plan-do-study-act cycles for planning and executing local improvement activities. The intervention group will receive an innovative stepped strategy comprising four levels of intensity of support. Implementation starts with generic low-cost activities and may build up to the highest level of tailored and labour-intensive activities. The decision for a stepwise increase in intensive support will be based on the success of implementation so far. Both implementation strategies will be completed within 1 year and evaluated on effect, process, and cost-effectiveness. The primary outcome is length of postoperative hospital stay. Additional outcome measures are length of recovery, guideline adherence, and mean implementation costs per patient.

Discussion

This study takes up the challenge to evaluate an efficient strategy for large-scale implementation. Comparing effectiveness and costs of two different approaches, this study will help to define a preferred strategy for nationwide dissemination of best practices.

Trial registration

Dutch Trial Register NTR4058

A detailed report of the resource use and costs associated with implementation of a short stay programme for breast cancer surgery

BACKGROUND

Despite the increased attention for assessing the effectiveness of implementation strategies, most implementation studies provide little or no information on its associated costs. The focus of the current study was to provide a detailed report of the resource use and costs associated with implementation of a short stay programme for breast cancer surgery in four Dutch hospitals.

METHODS

The analysis was performed alongside a multi-centre implementation study. The process of identification, measurement and valuation of the implementation activities was based on recommendations for the design, analysis and reporting of health technology assessments. A scoring form was developed to prospectively determine the implementation activities at professional and implementation expert level. A time horizon of 5 years was used to calculate the implementation costs per patient.

RESULTS

Identified activities were consisted of development and execution of the implementation strategy during the implementation project. Total implementation costs over the four hospitals were €83.293. Mean implementation costs, calculated for 660 patients treated over a period of 5 years, were €25 per patient. Subgroup analyses showed that the implementation costs ranged from €3.942 to €32.000 on hospital level. From a local hospital perspective, overall implementation costs were €21 per patient, after exclusion of the costs made by the expert centre.

CONCLUSIONS

We provided a detailed case description of how implementation costs can be determined. Notable differences in implementation costs between hospitals were observed.

TRIAL REGISTRATION

ISRCTN

ISRCTN77253391.

Adopting ambulatory breast cancer surgery as the standard of care in an asian population

Introduction. Ambulatory surgery is not commonly practiced in Asia. A 23-hour ambulatory (AS23) service was implemented at our institute in March 2004 to allow more surgeries to be performed as ambulatory procedures. In this study, we reviewed the impact of the AS23 service on breast cancer surgeries and reviewed surgical outcomes, including postoperative complications, length of stay, and 30-day readmission. Methods. Retrospective review was performed of 1742 patients who underwent definitive breast cancer surgery from 1 March 2004 to 31 December 2010. Results. By 2010, more than 70% of surgeries were being performed as ambulatory procedures. Younger women (P < 0.01), those undergoing wide local excision (P < 0.01) and those with ductal carcinoma-in situ or early stage breast cancer (P < 0.01), were more likely to undergo ambulatory surgery. Six percent of patients initially scheduled for ambulatory surgery were eventually managed as inpatients; a third of these were because of perioperative complications. Wound complications, 30-day readmission and reoperation rates were not more frequent with ambulatory surgery. Conclusion. Ambulatory breast cancer surgery is now the standard of care at our institute. An integrated workflow facilitating proper patient selection and structured postoperativee outpatient care have ensured minimal complications and high patient acceptance.

'23 h Model' for breast surgery: an early experience

The principles of fast track surgery are well established in colorectal surgery. It is an evidence based model aimed at reducing length of stay, convalescence and morbidity by optimising both clinical and organisational factors. Despite this, the implementation of fast track surgery in breast cancer patients has been slow. The 23 h discharge model for breast cancer surgery patients has been outlined by the NHS Improvement Programme and is a breakthrough from traditional inpatient care. This paper outlines the early experience of implementation of this model in a single institution during a 3-month audit period. Over 80% of patients undergoing non-reconstructive breast surgery were discharged safely within '23 h'. This suggests that good communication links, reorganisation of existing resources, active user involvement (both patients and clinical team) and strong project management ensures fast-tracking to be safe for the patient with significant economic benefits for the hospital.

Sustainability of healthcare innovations (SUSHI): long term effects of two implemented surgical care programmes (protocol)

Background

Two healthcare innovations were successfully implemented using different implementation strategies. First, a Short Stay Programme for breast cancer surgery (MaDO) was implemented in four early adopter hospitals, using a hospital-tailored implementation strategy. Second, the Enhanced Recovery After Surgery (ERAS) programme for colonic surgery was implemented in 33 Dutch hospitals, using a generic breakthrough implementation strategy. Both strategies resulted in a shorter hospital length of stay without a decrease in quality of care. Currently, it is unclear to what extent these innovative programmes and their results have been sustained three to five years following implementation. The aim of the sustainability of healthcare innovations (SUSHI) study is to analyse sustainability and its determinants using two implementation cases.

Methods

This observational study uses a mixed methods approach. The study will be performed in 14 hospitals in the Netherlands, from November 2010. For both implementation cases, the programme aspects and the effects will be evaluated by means of a follow-up measurement in 160 patients who underwent breast cancer surgery and 300 patients who underwent colonic surgery. A policy cost-effectiveness analysis from a societal perspective will be performed prospectively for the Short Stay Programme for breast cancer surgery in 160 patients. To study determinants of sustainability key professionals in the multidisciplinary care processes and implementation change agents will be interviewed using semi-structured interviews.

Discussion

The concept of sustainability is not commonly studied in implementation science. The SUSHI study will provide insight in to what extent the short-term implementation benefits have been maintained and in the determinants of long-term continuation of programme activities.