Douglas Coyle

Evaluating Survivorship Care Plans: Results of a Randomized, Clinical Trial of Patients With Breast Cancer

PURPOSE An Institute of Medicine report recommends that patients with cancer receive a survivorship care plan (SCP). The trial objective was to determine if an SCP for breast cancer survivors improves patient-reported outcomes. PATIENTS AND METHODS Women with early-stage breast cancer who completed primary treatment at least 3 months previously were eligible. Consenting patients were allocated within two strata: less than 24 months and ≥ 24 months since diagnosis. All patients were transferred to their own primary care physician (PCP) for follow-up. In addition to a discharge visit, the intervention group received an SCP, which was reviewed during a 30-minute educational session with a nurse, and their PCP received the SCP and guideline on follow-up. The primary outcome was cancer-related distress at 12 months, assessed by the Impact of Event Scale (IES). Secondary outcomes included quality of life, patient satisfaction, continuity/coordination of care, and health service measures. RESULTS Overall, 408 survivors were enrolled through nine tertiary cancer centers. There were no differences between groups on cancer-related distress or on any of the patient-reported secondary outcomes, and there were no differences when the two strata were analyzed separately. More patients in the intervention than control group correctly identify their PCP as primarily responsible for follow-up (98.7% v 89.1%; difference, 9.6%; 95% CI, 3.9 to 15.9; P = .005). CONCLUSION The results do not support the hypothesis that SCPs are beneficial for improving patient-reported outcomes. Transferring follow-up to PCPs is considered an important strategy to meet the demand for scarce oncology resources. SCPs were no better than a standard discharge visit with the oncologist to facilitate transfer.

Wage Losses in the Year After Breast Cancer: Extent and Determinants Among Canadian Women

BACKGROUND Wage losses after breast cancer may result in considerable financial burden. Their assessment is made more urgent because more women now participate in the workforce and because breast cancer is managed using multiple treatment modalities that could lead to long work absences. We evaluated wage losses, their determinants, and the associations between wage losses and changes for the worse in the familys financial situation among Canadian women over the first 12 months after diagnosis of early breast cancer. METHODS We conducted a prospective cohort study among women with breast cancer from eight hospitals throughout the province of Quebec. Information that permitted the calculation of wage losses and information on potential determinants of wage losses were collected by three pretested telephone interviews conducted over the year following the start of treatment. Information on medical characteristics was obtained from medical records. The main outcome was the proportion of annual wages lost because of breast cancer. Multivariable analysis of variance using the general linear model was used to identify personal, medical, and employment characteristics associated with the proportion of wages lost. All statistical tests were two-sided. RESULTS Among 962 eligible breast cancer patients, 800 completed all three interviews. Of these, 459 had a paying job during the month before diagnosis. On average, these working women lost 27% of their projected usual annual wages (median = 19%) after compensation received had been taken into account. Multivariable analysis showed that a higher percentage of lost wages was statistically significantly associated with a lower level of education (P(trend) = .0018), living 50 km or more from the hospital where surgery was performed (P = .070), lower social support (P = .012), having invasive disease (P = .086), receipt of chemotherapy (P < .001), self-employment (P < .001), shorter tenure in the job (P(trend) < .001), and part-time work (P < .001). CONCLUSION Wage losses and their effects on financial situation constitute an important adverse consequence of breast cancer in Canada.

Effect of Exercise Training on Physical Fitness in Type II Diabetes Mellitus

UNLABELLED Few studies have compared changes in cardiorespiratory fitness between aerobic training only or in combination with resistance training. In addition, no study to date has compared strength gains between resistance training and combined exercise training in type II diabetes mellitus (T2DM). PURPOSE We evaluated the effects of aerobic exercise training (A group), resistance exercise training (R group), combined aerobic and resistance training (A + R group), and sedentary lifestyle (C group) on cardiorespiratory fitness and muscular strength in individuals with T2DM. METHODS Two hundred and fifty-one participants in the Diabetes Aerobic and Resistance Exercise trial were randomly allocated to A, R, A + R, or C. Peak oxygen consumption (V O(2peak)), workload, and treadmill time were determined after maximal exercise testing at 0 and 6 months. Muscular strength was measured as the eight-repetition maximum on the leg press, bench press, and seated row. Responses were compared between younger (aged 39-54 yr) and older (aged 55-70 yr) adults and between sexes. RESULTS VO(2peak) improved by 1.73 and 1.93 mL O(2)*kg(-1)*min(-1) with A and A + R, respectively, compared with C (P < 0.05). Strength improvements were significant after A + R and R on the leg press (A + R: 48%, R: 65%), bench press (A + R: 38%, R: 57%), and seated row (A + R: 33%, R: 41%; P < 0.05). There was no main effect of age or sex on training performance outcomes. There was, however, a tendency for older participants to increase VO(2peak) more with A + R (+1.5 mL O(2)*kg(-1)*min(-1)) than with A only (+0.7 mL O(2)*kg(-1)*min(-1)). CONCLUSIONS Combined training did not provide additional benefits nor did it mitigate improvements in fitness in younger subjects compared with aerobic and resistance training alone. In older subjects, there was a trend to greater aerobic fitness gains with A + R versus A alone.

Ottawa panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis.

OBJECTIVE To update the Evidence-Based Clinical Practice Guidelines (EBCPGs) on aerobic walking programs for the management of osteoarthritis (OA) of the knee. DATA SOURCES A literature search was conducted using the electronic databases MEDLINE, PubMed, and the Cochrane Library for all studies related to aerobic walking programs for OA from 1966 until February 2011. STUDY SELECTION The literature search found 719 potential records, and 10 full-text articles were included according to the selection criteria. The Ottawa Methods Group established the inclusion and exclusion criteria regarding the characteristics of the population, by selecting adults of 40 years old and older who were diagnosed with OA of the knee. DATA EXTRACTION Two reviewers independently extracted important information from each selected study using standardized data extraction forms, such as the interventions, comparisons, outcomes, time period of the effect measured, and study design. The statistical analysis was reported using the Cochrane collaboration methods. An improvement of 15% or more relative to a control group contributes to the achievement of a statistically significant and clinically relevant progress. A specific grading system for recommendations, created by the Ottawa Panel, used a level system (level I for randomized controlled studies and level II for nonrandomized articles). The strength of the evidence of the recommendations was graded using a system with letters: A, B, C+, C, D, D+, or D-. DATA SYNTHESIS Evidence from 7 high-quality studies demonstrated that facility, hospital, and home-based aerobic walking programs with other therapies are effective interventions in the shorter term for the management of patients with OA to improve stiffness, strength, mobility, and endurance. CONCLUSIONS The greatest improvements were found in pain, quality of life, and functional status (grades A, B, or C+). A common limitation inherent to the EBCPGs is the heterogeneity of studies included with regards to the characteristics of the population, the interventions, the comparators, the outcomes, the period of time, and the study design. It is strongly recommended to use the Cochrane Risk of Bias Summary assessment to evaluate the methodologic quality of the studies and to consider avenues for future research on how aerobic walking programs would be beneficial in the management of OA of the hip.

Current status of economic appraisal of health technology in the European community: Report of the network

The use of economic evaluation to assess the costs and consequences of health care technologies has steadily increased in recent years. However, little is known about the influence economic studies have on health care decision makers or policy at local and national level. This paper reports the results of a survey of economic evaluations in EC countries to identify the impact of the results on decision and policy making in health care. Health service researchers in 10 EC countries were identified and asked to participate in the survey. The researchers were asked to locate economic evaluations in their country and complete a standardised questionnaire for each study. The criteria for inclusion in the survey were first, the studies should have been started or reported since 1987, second, the evaluations should include a comparison of the cost and consequences of the technologies assessed and finally, the appraisals should include a comparison of alternative health care technologies or programmes. A total of 66 studies which met the survey criteria were reported. Of these, 27% were thought to have influenced health care decision makers or policy. The results suggested that method of dissemination, source of funding and purpose of the study may be important determinants of whether an economic evaluation will be used in health care policy or decision making. The results of the survey suggest that economic evaluation currently has a relatively low impact on health care policy or decision making.(ABSTRACT TRUNCATED AT 250 WORDS)

Discounting of Health Benefits in the Pharmacoeconomic Analysis of Drug Therapies

SummaryIn most economic evaluations. future monetary costs and benefits and future health benefits are discounted at the same rate. The purpose of this article is to question such current practice. The primary reason behind discounting costs and benefits is to allow for individuals’ preferences over the timing of such events, i.e. to represent social time preference. We argue that the social time preference rate for health benefits is unlikely to be the same as that for monetary costs and benefits. The results of a sensitivity analysis of pharmacoeconomic analyses of drug treatments for hypertension illustrate how the choice of discount rate can affect the conclusions. As no definite conclusions can be drawn regarding the magnitude of the discount rate for health benefits, we recommend that analysts conduct sensitivity analyses employing differential discount rates for health benefits as well as monetary costs and benefits.

Statistical analysis in pharmacoeconomic studies : a review of current issues and standards

SummaryThe increasing number of economic evaluations of healthcare interventions, and of drug therapies in particular, has been well documented. However, surveys have demonstrated that standards of conduct of such studies have not similarly increased. Of particular concern is the lack of development or even consideration of statistical techniques in the reporting of studies. This article addresses issues that must be considered both in the conduct and in the assessment of the quality of studies. Throughout the paper, examples of pharmacoeconomic analyses are used to illustrate the points made.Recommendations for the conduct of future pharmacoeconomic studies are given. Such recommendations specifically relate to the level of testing that is conducted, the choice of statistical tests and the manner in which statistical significance is reported. In addition, existing methods for the statistical analysis of cost-effectiveness ratios and for the determination of sample size in economic evaluations are discussed, and a partial solution to this issue is offered.

Economic burden of hepatitis C in Canada and the potential impact of prevention

This Canadian hepatitis C model estimates economic burden of disease using Markov modeling to predict progression over 11 health states annually from 2001 to 2040. Incidence-based estimates help demonstrate the capability to determine cost-effectiveness of programs to prevent different proportions of incident cases. Benefits of prevention increase linearly with the number of incident cases prevented. The model forecasts annual health care costs for the treatment of HCV-related disease ranging from

Impact of Particulate Air Pollution on Quality-Adjusted Life Expectancy in Canada

103 to

Cost Effectiveness of Epoetin-alpha to Augment Preoperative Autologous Blood Donation in Elective Cardiac Surgery

158 million over time. Health care costs attributable to 2001 incidence cohort are forecast at