Measuring quality of care in the treatment of colorectal cancer: The Moffitt Network Initiative on Practice Quality (MNIPQ)

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Background: As the first step in a larger effort to improve quality of care among its member institutions, the MNIPQ sought to develop and implement methods to assess quality of care in the treatment of colorectal cancer. The current report focuses on our initial experience conducting quality assessments at 4 of 20 member institutions. Methods: Medical chart reviews were conducted of all patients diagnosed with colon or rectal cancer in 2004 and seen by a medical oncologist at the Moffitt Cancer Center or at any of three affiliate institutions. Abstractors, who were trained and periodically monitored, conducted the reviews using a web-based abstraction tool. Abstraction focused on assessing adherence to quality indicators consistent with evidence-, consensus-, and regulatory-based guidelines. Variability in adherence across sites was evaluated by conducting Fisher’s exact tests. The 186 patients whose charts were reviewed were predominantly female (57%) and diagnosed with colon cancer (74%). Results: Adherence was consistently (p values>.05) high across all four study sites for: presence of a pathology report confirming malignancy (91–100%); evidence of staging based on established criteria (88–94%); documentation of discussion or referral for chemotherapy in cases of lymph node (colon and rectal cancer) or rectal wall (rectal cancer) involvement (89–100%); and presence of chemotherapy flow sheets (92–100%). Adherence was consistently (p values>.05) lower across sites for: performance of complete colon evaluation within 12 months of surgery (24–47%) and performance of CEA test before (48–74%) or in the 6 months after (56–82%) surgery or chemotherapy. Adherence varied significantly (p < .001) across sites only for documentation of consent for patients treated with chemotherapy (41–100%). Discussion: Findings identified several areas where efforts should be made to improve the quality of colorectal cancer care at one or more member institutions. In addition, the methods developed have laid the groundwork for future efforts to measure and improve quality of care for other cancers and among a larger number of member institutions.

No significant financial relationships to disclose.

Cost analysis of sentinel lymph node biopsy as an alternative to elective lymph node dissection in patients with malignant melanoma

In the current era of managed care and cost containment, physicians and administrators are placed in the predicament of increasing quality of care while decreasing costs. The purpose of this article is to offer a cost analysis, while also demonstrating what patients, providers, payers, employers, and industry may stand to gain from establishing sentinel lymph node biopsy as a standard care in certain groups of patients.

Managed care organizations and mammography: opportunities to serve underserved women

Breast cancer is one of the major causes of mortality and morbidity among women. Breast cancer screening (mammography) has been shown to be an effective preventive service. Significant proportions of women for whom mammography would be an appropriate intervention, especially older, low-income, and minority women, do not receive it. A large proportion of American women (including those in the workforce or who are Medicare and Medicaid beneficiaries) is now enrolled in managed care plans and that trend is likely to continue. Analysts have identified several concerns related to access and use of preventive services by low-income and other vulnerable populations. Research related to these concerns is summarized. Many research-based interventions have been identified that increase the likelihood of women receiving mammography. These are summarized and recommendations are made for managed care organizations to implement them.

Oral formulations of adefovir dipivoxil: in vitro dissolution and in vivo bioavailability in dogs

The effect of formulation on oral bioavailability of the antiviral nucleotide analogue adefovir from the prodrug adefovir dipivoxil was examined in beagle dogs. A suspension formulation of adefovir dipivoxil granules was administered to five fasted male beagle dogs (250 mg prodrug per dog; 135.7 mg-equiv of adefovir per dog). Tablets prepared from the same granulation (batch B94) were administered at 2 x 125 mg prodrug per dog. In addition, the same tablets were administered to dogs in the fed state or following pentagastrin pretreatment. Two further tablet batches (H94 and D501) with slight formulation changes were also evaluated in pentagastrin pretreated dogs (n = 5). Concentrations of adefovir in plasma were determined by HPLC following fluorescence derivatization. Tablet dissolution was examined at pH 2.0. One batch of adefovir dipivoxil tablets showed a 5-fold slower dissolution rate in vitro (B94 = H94 >> D501). Adefovir dipivoxil was completely converted to adefovir following oral absorption in dogs. The oral bioavailability of adefovir from the suspension was 35.0 +/- 8.9%. The oral bioavailability of adefovir from the tablet formulation was 34.7 +/- 10.3%, 37.2 +/- 4.5%, and 44.9 +/- 5.9% in fasted dogs, fed dogs and fasted dogs pretreated with pentagastrin, respectively. All three tablet batches had equivalent bioavailability in dogs. Oral bioavailability of adefovir from the prodrug in dogs (35-46%) was unaffected by formulation, food, or the acidic pH of the gastrointestinal tract. In vitro dissolution of adefovir dipivoxil tablets did not correlate with oral bioavailability. Oral bioavailability of adefovir dipivoxil appears to be limited by low permeability and biological conversion of the prodrug to adefovir.

Investment in new technology research can save future health care dollars

OBJECTIVE

To perform a cost analysis of the emerging technology of lymphatic mapping for patients with malignant melanoma.

DESIGN

A retrospective, computer-aided chart and financial cost and charge review of consecutive patients with the diagnosis of melanoma registered at a cancer center from December, 1995 to March, 1996.

PARTICIPANTS

73 consecutive patients with the diagnosis of Stage 1 and 2 melanoma (cutaneous disease only) had nodal staging of their disease with either a sentinel node (SLN) biopsy or an elective complete node dissection (ELND). This was determined largely by patient choice and the protocol in operation at the time of the presentation of the patient to the clinic.

OUTCOMES MEASURED

There were no deaths in the series. Patient morbidity endpoints included rates of infection, incidence of extremity lymphedema, development of a seroma in the regional nodal basin wound and wound healing. Clinical outcome was measured by the ability to obtain complete nodal staging information with the new lymphatic mapping technology, and recurrence rates in the nodal basin after a negative SLN biopsy. Total charges, direct costs and total costs were calculated from all hospital, OR, pathology and lab charges. Professional fees were included in the analysis.

RESULTS

Group 1 patients (50) had melanomas greater than 0.76 mm in thickness treated with a wide local excision (WLE), lymphatic mapping and SLN biopsy under general anesthesia. Five patients (Group 2) had their procedure performed under a straight local anesthesia. Group 3 patients (18) had nodal staging performed with an elective node dissection. In Groups 1 and 2, if the SLN was positive for micrometastases, the patients were taken back to the OR for a complete node dissection. The total charges per patient were $13,835, $6,853 and $19,285, respectively. Significant dollar savings were achieved if the nodal staging could be accomplished with the lymphatic mapping technology (p = 0.001). Morbidity was significantly less in Groups 1 and 2 compared to Group 3. After a mean follow-up of three years, only one patient has recurred in a SLN negative basin.

CONCLUSIONS

With 38,300 new cases of melanoma diagnosed each year in the United States, a projected savings of $172 million per year (general anesthesia) and $350 million per year (local anesthesia) could be realized if this new mapping technology could be incorporated into the care of the melanoma patient. Patient morbidity is minimized, nodal staging is complete and patients return to work sooner. Recently approved adjuvant therapy can be applied in a selective fashion, treating only those patients in which a documented benefit has been obtained, saving the health care system more dollars. Initial investment in defining the technology was minimal.

Prostate cancer screening

Prostate cancer is a common cancer and a leading cause of cancer death in men. It is potentially detectable at early, possibly curative stages through various combinations of testing, including DRE, PSA, and TRUS of the prostate. Still unproven is the effectiveness of prostate cancer treatment, and because of that lack of proof, the optimal screening strategies are also elusive. It is possible that what is known as prostate cancer today may be, in fact, multiple entities with different natural histories, different treatment needs, and, consequently, different screening strategies. The role of informed consent has been suggested as a means to involve patients in the decision process, especially because the literature presents an environment of intense controversy. It is hoped that the PIVOT trial or similar efforts and further research into the basic mechanisms of the disease will provide clearer answers in the future.

A national profile of the use of intensive care by Medicare patients with cancer

BACKGROUND

The broad picture of intensive care unit (ICU) outcomes and expenditures cannot be discerned from previous studies that were conducted at single hospitals and focused on narrow subsets of patients.

METHODS

This study provides a comprehensive national profile of ICU used by Medicare patients with cancer. The data source was the Medicare Provider Analysis and Review file for fiscal year 1990, representing 100% of all hospital admissions that occurred within 723 ICD-9-CM codes and organized into 11 code groups. Using screening criteria, admissions were categorized as surgical (both major and minor procedures) or nonsurgical (no procedures) and with and without involvement of the ICU. The categories were compared using the following outcome variables: total hospital charges, ICU charges, ancillary charges, average length of stay, and in-hospital mortality.

RESULTS

This study population accounted for nearly 800,000 admissions, of which 143,458 (18.1%) involved the use of the ICU. Actual ICU charges represented 4.9% of the $9.3 billion in total hospital charges. Intensive care unit use is associated positively with service intensity, and 73% of all the admissions involving the ICU were for major procedures. Only 2% involved no procedures. Admissions involving use of the ICU generate higher charges and longer lengths of stay than non-ICU admissions, although the differences decrease with declining treatment intensity and resource use. In-hospital mortality rates, for those cases that used the ICU, were 9.8% for major procedures, 21.2% for minor procedures, and 37.6% for cases involving no procedures.

CONCLUSIONS

Contrary to the conclusions drawn from previous research, these findings suggest that patients who receive less intense service and use fewer hospital resources are more likely to die in the hospital than those who receive more care, with or without a stay in the ICU during the hospitalization. A global view of ICU use does not support the conclusion that a disproportionate share of special care resources is expended on futile care of the terminally ill or excessive monitoring of low risk patients, although these problems undoubtedly exist. Analysis of comprehensive national data regarding the use of intensive care provides a perspective that challenges some of the conclusions based on more limited studies that were conducted in single hospitals and focused on nonsurvivors or subsets of patients narrowly defined in other ways.

Mass mammography screening: using an information system to track participation and identify target populations

This article describes the 1991 American Cancer Society Greater Tampa Bay Breast Screening Program and an information system developed to track participants from the point of inquiry to mammography results. Information from three sources was linked to create a comprehensive data base, including participant demographics, mammography history, perceived risks of breast cancer, barriers to mammography, and mammography results. This comprehensive data base allowed investigators to describe the 11,134 participants and to assess the program's impact. The analysis suggested that women older than 65 years are underrepresented in this voluntary program. Black women were less likely to participate, as were women in lower income and education groups. To reduce mortality effectively, leaders of mass screening programs need to develop creative strategies for reaching these high-risk groups. Effective information systems can identify program weaknesses and track the impact of changes.

A feedback system for reducing excessive laboratory tests

At the James A. Haley Veterans Hospital in Tampa, Fla, a program has been implemented to reduce the amount of potentially excessive laboratory testing. The major program components are a set of test frequency guidelines and a system of feedback to resident physicians that compares their test ordering patterns against the predetermined guidelines. The guidelines are analyte specific and differentiate between normal and abnormal test values reported during 1-day and 7-day time periods. The feedback process includes both systematic reporting of objective data and individual and group education and counseling sessions related to the appropriate use of laboratory tests. A reduction in the percentage of tests that fell outside the guidelines (outliers) was achieved following implementation of the program.