Model for the cost-efficient delivery of continuous quality cancer care: a hospital and private-practice collaboration

Cancer care is expensive due to the high costs of treatment and preventable utilization of resources. Government, employer groups, and insurers are seeking cancer care delivery models that promote both cost-efficiency and quality care. Baylor University Medical Center at Dallas (BUMC), a large tertiary care hospital, in collaboration with Texas Oncology, a large private oncology practice, established two independent centers that function cooperatively within the Baylor Charles A. Sammons Cancer Center, the Oncology Evaluation and Treatment Center (OETC) and Infusion Center, to deliver urgent care and infusions after hours to oncology patients. Quality measures based on evidence-based care and cost-efficiency measures were implemented within these centers. Ability to meet predetermined goals for these measures will be a guide for implementing continuous quality and cost-efficiency interventions. During the first two quarters of operations, 2023 patients received care in the OETC (n = 423) and Infusion Center (n = 1600). The average time spent in the OETC was 48% less than the time spent in the BUMC emergency department (ED). Eighty-nine percent of the cancer center' patients who received urgent care at BUMC were referred to the OETC for this care, instead of the BUMC ED. The hospital admission rate in the OETC was 59% lower than it was in the BUMC ED, a high-volume level I trauma center. The addition of the OETC and Infusion Center to the cancer center holds promise for providing continuous quality cancer care that is cost-efficient.

Lifestyle, genes, and cancer

It is estimated that almost 1.5 million people in the USA are diagnosed with cancer every year. However, due to the substantial effect of modifiable lifestyle factors on the most prevalent cancers, it has been estimated that 50% of cancer is preventable. Physical activity, weight loss, and a reduction in alcohol use can strongly be recommended for the reduction of breast cancer risk. Similarly, weight loss, physical activity, and cessation of tobacco use are important behavior changes to reduce colorectal cancer risk, along with the potential benefit for the reduction of red meat consumption and the increase in folic acid intake. Smoking cessation is still the most important prevention intervention for reducing lung cancer risk, but recent evidence indicates that increasing physical activity may also be an important prevention intervention for this disease. The potential benefit of lifestyle change to reduce prostate cancer risk is growing, with recent evidence indicating the importance of a diet rich in tomato-based foods and weight loss. Also, in the cancers for which there are established lifestyle risk factors, such as physical inactivity for breast cancer and obesity for colorectal cancer, there is emerging information on the role that genetics plays in interacting with these factors, as well as the interaction of combinations of lifestyle factors. Integration of genetic information into lifestyle factors can help to clarify the causal relationships between lifestyle and genetic factors and assist in better identifying cancer risk, ultimately leading to better-informed choices about effective methods to enhance health and prevent cancer.

Role of physical activity in modulating breast cancer risk as defined by APC and RASSF1A promoter hypermethylation in nonmalignant breast tissue

Physical activity reduces breast cancer risk. Promoter hypermethylation of the tumor suppressor genes APC and RASSF1A, which is potentially reversible, is associated with breast cancer risk. We conducted a cross-sectional study in 45 women without breast cancer to determine the association of physical activity with promoter hypermethylation of APC and RASSF1A in breast tissue. We used quantitative methylation-specific PCR to test the methylation status of APC and RASSF1A, and questionnaires to assess study covariates and physical activity (measured in metabolic equivalent hours per week). In univariate analyses, the study covariate, benign breast biopsy number, was positively associated with promoter hypermethylation of APC (P = 0.01) but not RASSF1A. Mulitvariate logistic regression indicated that, although not significant, physical activities for a lifetime [odds ratio (OR), 0.57; 95% confidence interval (95% CI), 0.22-1.45; P = 0.24], previous 5 years (OR, 0.62; 95% CI, 0.34-1.12; P = 0.11), and previous year (OR, 0.72; 95% CI, 0.43-1.22; P = 0.22) were inversely related to promoter hypermethylation of APC but not RASSF1A for all physical activity measures. Univariate logistic regression indicated that physical activities for a lifetime, previous 5 years, and previous year were inversely associated with benign breast biopsy number, and these results were approaching significance for lifetime physical activity (OR, 0.41; 95% CI, 0.16-1.01; P = 0.05) and significant for physical activity in the previous 5 years (OR, 0.57; 95% CI, 0.34-0.94; P = 0.03). The study provides indirect evidence supporting the hypothesis that physical activity is inversely associated with promoter hypermethylation of tumor suppressor genes, such as APC, in nonmalignant breast tissue.

An ecological study of the association of metal air pollutants with lung cancer incidence in Texas

BACKGROUND

Air pollution particulate matter and tobacco smoke, which contain metals that are human lung carcinogens, are associated with lung cancer risk. We conducted an ecological study to examine the association of metal air pollutants with lung cancer incidence in Texas.

METHODS

During the period 1995 to 2000, 81,132 lung cancer cases were reported in Texas. We identified eight metals that (1) are in airborne particulate matter or tobacco smoke or are human lung carcinogens and (2) had consistent Environmental Protection Agency air release reporting for multiple counties from 1988 through 2000. We examined the association of metal air releases with the average annual age-adjusted primary and non-small cell lung cancer rates in the 254 Texas counties.

RESULTS

Univariate analysis indicated the following positive associations: (1) zinc with the primary (p = 0.02) and non-small cell (p < 0.01) lung cancer rates and (2) chromium and copper with the non-small cell lung cancer rate, p = 0.01 and p = 0.01, respectively. In the multivariate analyses, risk adjusted for sex, race and ethnicity, and urbanization, zinc was positively associated with the primary (beta = 0.13, p = 0.01) and non-small cell (beta = 0.14, p = 0.02) lung cancer rates, and when interaction terms among the eight metals were included, zinc was significantly and positively associated with these rates. Smoking prevalence was similar for counties with and without releases for the eight metals.

CONCLUSIONS

The study suggests that inhalation exposure to metals, including those that are essential human nutrients, play a role in lung carcinogenesis.

Effectiveness of a graduate medical education program for improving medical event reporting attitude and behavior

OBJECTIVES

To evaluate the effectiveness of an educational program for improving medical event reporting attitude and behavior in the ambulatory care setting among graduate medical trainees.

DESIGN

One group pre- and post-test study.

SETTING

The University of Texas Southwestern Medical Center at Dallas Family Medicine Residency Program.

PARTICIPANTS

All family practice residents (n = 30).

INTERVENTION

Patient safety educational program implemented through an introductory lecture and 6 monthly conferences, June to December 2002, involving medical events that occurred in the ambulatory care setting.

OUTCOME MEASURES

Medical event reporting attitude and behavior at baseline and at 6 month follow up, and barriers to medical event reporting at the 6 month follow up.

RESULTS

Program attendance was significantly correlated with medical event reporting attitude and behavior change (rho = 0.525, p = 0.003). The median change in medical event reporting attitude and behavior was zero and not statistically significant (p = 0.566). Major barriers to medical event reporting were lack of time, extra paper work, and concern about career and personal reputation.

CONCLUSIONS

Attending the patient safety educational program was key for promoting a positive medical event reporting attitude and behavior change among graduate trainees. Major barriers to medical event reporting were lack of time, extra paper work, and concern about career and personal reputation. Future research will need to focus on reducing these barriers and to evaluate the effectiveness of such a program over longer periods of time, since making a positive change in medical event reporting attitude and behavior must be made at the individual and organizational levels.

An ecological study of the association of environmental chemicals on breast cancer incidence in Texas

PURPOSE

To investigate the role of environment in breast cancer development, we conducted an ecological study to examine the association of releases for selected industrial chemicals with breast cancer incidence in Texas.

METHODS

During 1995--2000, 54,487 invasive breast cancer cases were reported in Texas. We identified 12 toxicants released into the environment by industry that: (1) were positively associated with breast cancer in epidemiological studies, (2) were Environmental Protection Agency (EPA) Toxics Release Inventory (TRI) chemicals designated as carcinogens or had estrogenic effects associated with breast cancer risk, and (3) had releases consistently reported to EPA TRI for multiple Texas counties during 1988--2000. We performed univariate, and multivariate analyses adjusted for race and ethnicity to examine the association of releases for these toxicants during 1988--2000 with the average annual age-adjusted breast cancer rate at the county level.

RESULTS

Univariate analysis indicated that formaldehyde, methylene chloride, styrene, tetrachloroethylene, trichloroethylene, chromium, cobalt, copper, and nickel were positively associated with the breast cancer rate. Multivariate analyses indicated that styrene was positively associated with the breast cancer rate in women and men (beta=0.219, p=.004), women (beta=0.191, p=0.002), and women >or= 50 years old (beta=0.187, p=0.002).

CONCLUSION

Styrene was the most important environmental toxicant positively associated with invasive breast cancer incidence in Texas, likely involving women and men of all ages. Styrene may be an important breast carcinogen due to its widespread use for food storage and preparation, and its release from building materials, tobacco smoke, and industry.

Predictors of short-term clinical response to acute asthma care in adults

OBJECTIVE

We assessed the effects of potential patient risk factors on short-term clinical response to acute asthma care among adults who often require emergency department (ED) visits and hospitalizations to manage their asthma.

DESIGN AND SETTING

Prospective cohort study that included adult patients treated for acute asthma, which was conducted in a US public hospital ED between March 1997 and August 1999, with a 2- to 3-week follow-up.

STUDY PARTICIPANTS

Three hundred and nine patients completed the study.

MAIN MEASURES

We identified patient risk factors that predicted lower peak expiratory flow rate (PEFR) change over 2-3 weeks following acute asthma care. Potential risk factors were ozone exposure, indoor allergy and exposure, smoking, upper respiratory infection in the last month, lower asthma knowledge, and medication non-adherence.

RESULTS

Univariate analyses indicated that lower asthma knowledge significantly and positively correlated with lower PEFR change (r = 0.15, P = 0.01). Multivariate analysis that controlled for patient case-mix indicated that indoor allergy and exposure [b = 32.76, 95% confidence interval (CI) = 3.98-61.53, P = 0.03] significantly predicted lower PEFR change. There was no change in the multivariate analysis when the absence of treatment with corticosteroids during the 2-3 weeks before follow-up was added as a potential patient risk factor.

CONCLUSION

The study suggests that interventions are needed to target the patient risk factors, indoor allergen exposure, and poor asthma knowledge, to promote short-term clinical response to acute asthma care in adults, especially among economically disadvantaged inner-city residents.

The use of parent report to assess the quality of care in primary care visits among children with asthma

OBJECTIVE

To determine the accuracy of parent report and the accuracy of the medical record in documenting physician performance of elements of pediatric asthma care in the primary care setting.

METHODS

A convenience sample of 79 English-speaking parents of 4--12-year old children with asthma presenting to medical center--affiliated inner-city primary care pediatric clinics in the Bronx, Dallas, and Chicago was enrolled, and the office visit was audiotaped. Parents were interviewed 1--16 days after the visit by telephone.

OUTCOME MEASURES

Accuracy of parent report was the primary outcome. The "reference standard" was an independent evaluation of the audiotaped record of the primary care visit. The National Asthma Education and Prevention Program was used as a guide to select data elements to assess quality of pediatric asthma care during primary care visits.

RESULTS

Sufficient documentation was significantly (P <.001) less likely to be present in the medical record than in the follow-up interview for each element of care. When these elements were combined into a cumulative score, 71% of parent interviews but only 37% of medical records scored > or = 5 (out of a possible 6), with 29% of medical records scoring < 3. Parents were able to accurately report (concordance of parent data with audiotape reference standard) whether or not the visit had included performance of 5 of the 6 elements of care.

CONCLUSIONS

Our study suggests that parent telephone interview within 2 weeks after the visit is more accurate than the medical record for documentation of the quality of asthma care in pediatric primary care visits. The medical record was not sufficient to assess the quality of primary care related to asthma, primarily because of missing data. Therefore, our data suggest that assessing quality of care using the medical record will not only bias the findings in the direction of more deficient care but will also make improvement in care more difficult. Further validation of our strategy for using parent report to assess the quality of care in primary care visits will require its application in a variety of other primary care settings.

Developing theoretical constructs for outcomes research

BACKGROUND

In March of 1998, The Advisory Commission on Consumer Protection and Quality in Health Industry released a report in response to the US Presidential Executive Order that recommended increasing funding for outcomes research. This report indicated that outcomes research was critical to assessing the effectiveness of treatment and the quality of care.

METHODS

A systematic review was conducted of the pertinent English literature that describes the development, methods, and limitations of outcomes research to identify methods for minimizing its limitations.

RESULTS

Current evidence indicates that approximately 80% of commonly used medical treatments have not been shown to be efficacious, primarily because the necessary randomized controlled trials have not been conducted because of methodological problems, the time required for their execution, the expense, or ethical reasons. Therefore, physicians disagree on the value of many common clinical practices, which is reflected in the large variation in medical care prescribed for different populations. Outcomes research, which is conducted under actual clinical practice conditions using effectiveness studies, offers an efficient approach for investigating the link between medical care and outcomes. However, the major limitation of past outcomes research has been its limited ability to link medical care with outcomes, because of the lack of theory development to guide the research process, inadequate data sources, or both.

CONCLUSIONS

The literature review suggests that the use of pertinent theoretical constructs to guide the outcomes research process will generate the results needed to assess the effectiveness of treatment and the quality of care.

Measuring and predicting academic generalists' work satisfaction: implications for retaining faculty

PURPOSE

To develop a measure that could be used to identify interventions to improve the work satisfaction of academic generalists.

METHODS

To field-test the measure, the authors surveyed the generalist faculty at the University of Texas Southwestern Medical Center at Dallas. Ninety-four (80%) of the faculty responded. The measure's reliability was established using Cronbach's alpha, and its validity was established with the Pearson correlation coefficient using a previously validated global work-satisfaction measure. Using ten work-satisfaction dimensions and selected faculty characteristics, the authors performed univariate and stepwise multiple regression analyses to predict the generalist faculty's global work satisfaction and intentions of leaving their positions.

RESULTS

Work-satisfaction dimension predictors were autonomy in the workplace, professional status, teaching activities, clinical resources and activities, professional relationships, institutional governance, compensation, and professional advancement. Faculty characteristic predictors were gender, age, race or ethnicity, and living with children.

CONCLUSION

The measure includes eight valid and reliable work-satisfaction dimensions that predict global work satisfaction or intentions to leave. Others may want to use this measure, along with the four faculty-characteristic predictors, as a management tool for improving academic generalists' work satisfaction and, ultimately, their performances and retention.

Using antecedents of medical care to develop valid quality of care measures

OBJECTIVE

To present a new model for using the antecedents of medical care in outcomes assessment to develop valid quality of care measures.

METHODS

The pertinent literature describing the history of outcomes assessment and the influence of patient and environmental risk factors on health status were reviewed.

RESULTS

Past outcomes assessment studies have not consistently demonstrated a correlation between the processes and the outcomes of care. The use of the model described in this article indicates that the lack of correlation between process and outcome is probably because past outcomes assessment studies lacked the inclusion of medical care antecedents (primarily patient and environmental risk factors) that had a significant influence on the outcomes measured. Included is a description of a study that tests the utility of incorporating the antecedents of medical care into outcomes assessment to develop valid quality of care measures.

CONCLUSION

The model presented in this article advances quality of care measure development by using: (i) qualitative research to characterize the pertinent antecedents of medical care; and (ii) as many of the pertinent antecedents of medical care as possible to develop risk adjustment models for measuring outcomes that are more likely to identify the true linkages between the processes and outcomes of care. Knowing the linkages between the processes and outcomes of care would provide the information needed to develop valid quality of care measures, so that quality can be measured accurately and the groundwork for its improvement can be laid.

Developing strategic plans for academic general internal medicine

There is an increasing need to train more primary care physicians. Therefore, it would be advantageous for academic general internal medicine (GIM) to develop strategies to meet these demands. Our GIM division developed a strategic planning process with the participant groups being the division faculty, a pertinent literature review (the surrogate expert), and selected medical administrators. The IDEALS systems design provided the conceptual framework for the strategic planning process. This process used the Delphi technique to develop the theoretically ideal work system based on the division's vision for its future role, and the Nominal Group Process Technique to create the recommended work system, using the Delphi results. The strategic planning process was economical and division faculty agreed that it was useful.