Junya Zhu

Carboplatin and Paclitaxel With vs Without Bevacizumab in Older Patients With Advanced Non–Small Cell Lung Cancer

CONTEXT A previous randomized trial demonstrated that adding bevacizumab to carboplatin and paclitaxel improved survival in advanced non-small cell lung cancer (NSCLC). However, longer survival was not observed in the subgroup of patients aged 65 years or older. OBJECTIVE To examine whether adding bevacizumab to carboplatin and paclitaxel chemotherapy is associated with improved survival in older patients with NSCLC. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 4168 Medicare beneficiaries aged 65 years or older with stage IIIB or stage IV non-squamous cell NSCLC diagnosed in 2002-2007 in a Surveillance, Epidemiology, and End Results (SEER) region. Patients were categorized into 3 cohorts based on diagnosis year and type of initial chemotherapy administered within 4 months of diagnosis: (1) diagnosis in 2006-2007 and bevacizumab-carboplatin-paclitaxel therapy; (2) diagnosis in 2006-2007 and carboplatin-paclitaxel therapy; or (3) diagnosis in 2002-2005 and carboplatin-paclitaxel therapy. The associations between carboplatin-paclitaxel with vs without bevacizumab and overall survival were compared using Cox proportional hazards models and propensity score analyses including information about patient characteristics recorded in SEER-Medicare. MAIN OUTCOME MEASURE Overall survival measured from the first date of chemotherapy treatment until death or the censoring date of December 31, 2009. RESULTS The median survival estimates were 9.7 (interquartile range [IQR], 4.4-18.6) months for bevacizumab-carboplatin-paclitaxel, 8.9 (IQR, 3.5-19.3) months for carboplatin-paclitaxel in 2006-2007, and 8.0 (IQR, 3.7-17.2) months for carboplatin-paclitaxel in 2002-2005. One-year survival probabilities were 39.6% (95% CI, 34.6%-45.4%) for bevacizumab-carboplatin-paclitaxel vs 40.1% (95% CI, 37.4%-43.0%) for carboplatin-paclitaxel in 2006-2007 and 35.6% (95% CI, 33.8%-37.5%) for carboplatin-paclitaxel in 2002-2005. Neither multivariable nor propensity score-adjusted Cox models demonstrated a survival advantage for bevacizumab-carboplatin-paclitaxel compared with carboplatin-paclitaxel cohorts. In propensity score-stratified models, the hazard ratio for overall survival for bevacizumab-carboplatin-paclitaxel compared with carboplatin-paclitaxel in 2006-2007 was 1.01 (95% CI, 0.89-1.16; P = .85) and compared with carboplatin-paclitaxel in 2002-2005 was 0.93 (95% CI, 0.83-1.06; P = .28). The propensity score-weighted model and propensity score-matching model similarly failed to demonstrate a statistically significant superiority for bevacizumab-carboplatin-paclitaxel. Subgroup and sensitivity analyses for key variables did not change these findings. CONCLUSION Adding bevacizumab to carboplatin and paclitaxel chemotherapy was not associated with better survival among Medicare patients with advanced NSCLC.

US Cancer Center Implementation of ASCO/Oncology Nursing Society Chemotherapy Administration Safety Standards

PURPOSE Because cancer chemotherapy is a high-risk intervention, ASCO and the Oncology Nursing Society (ONS) established in 2009 consensus- and evidence-based national standards for the safe administration of chemotherapy. We sought to assess the implementation status of the ASCO/ONS chemotherapy administration safety standards. METHODS A written survey of chemotherapy practices was sent to National Cancer Institute-designated cancer centers. Implementation status of each of 31 chemotherapy administration safety standards was self-reported. RESULTS Forty-four (80%) of 55 eligible centers responded. Although the majority of centers have fully implemented at least half of the standards, only four centers reported full implementation of all 31. Implementation varied by standard, with the poorest implementation of standards that addressed documentation of chemotherapy planning, agreed-on intervals for laboratory testing, and patient education and consent before initiation of oral or infusional chemotherapy. CONCLUSION Given wide variation in the implementation of ASCO/ONS chemotherapy administration safety standards at US cancer centers, there are significant opportunities for improvement.

The you CAN campaign: Teamwork training for patients and families in ambulatory oncology

BACKGROUND Health care organizations have begun to adapt high-performance teamwork training techniques from aviation to clinical environments. Oncology care is often delivered in multispecialty teams and with the patients and familys active involvement. To examine the potential value of a patient-oriented teamwork intervention, a teamwork training initiative for oncology patients and their families was developed at the Dana-Farber Cancer Institute. DEVELOPING THE CAMPAIGN The content and format of the initiative evolved iteratively on the basis of several core team-training concepts derived from the research literature in health care and aviation. Initially a targeted intervention, the program evolved into a multifaceted campaign that included internal marketing, staff training, and one-on-one patient outreach by a group of volunteers. The You CAN campaign sought to convey a positive and empowering message that encouraged patients to (1) check for hazards in the environment, (2) ask questions of clinicians, and (3) notify staff of safety concerns. IMPLEMENTING THE CAMPAIGN The You CAN campaignwas conducted from July through September 2007. To assess its progress, patients were surveyed at baseline and during the campaign. On the basis of the survey results, 32% (95% confidence interval [CI]: 25%-38%) of the ambulatory clinic population, or 1,145 patients, were exposed to the campaign. Although patients rated the quality of teamwork and communication favorably at both baseline and followup, there was no significant change in the self-reported use of teamwork techniques on a written survey. However, 39% (95% CI: 27%-51%) of those who were exposed to the campaign said that it changed their behavior. DISCUSSION A training program for patients and their families is feasible in ambulatory oncology and may be applicable to other clinical settings.

Comparative effectiveness of three platinum-doublet chemotherapy regimens in elderly patients with advanced non-small cell lung cancer.

Randomized trials report equivalent efficacy among various combinations of platinum‐based regimens in advanced non–small cell lung cancer (NSCLC). Their relative effectiveness and comparability based on squamous versus nonsquamous histology is uncertain.

Identifying Women at Risk of Delayed Breast Cancer Diagnosis

BACKGROUND Delays in breast cancer diagnosis contribute to increased morbidity and mortality. Factors related to the occurrence of delayed diagnosis have not been well studied. METHODS A retrospective cohort study of 5,464 women newly diagnosed with breast cancer from 1999 through 2006 was conducted at a comprehensive cancer center in Boston. A delayed diagnosis was defined as an interval greater than 90 days between the patients first breast-related problem that prompted seeking of medical care and the breast cancer diagnosis based on biopsy. RESULTS 938 (17%) patients had a delayed breast cancer diagnosis. Non-white race or Hispanic ethnicity (adjusted odds ratio [OR] = 1.46, 95% confidence interval [CI] = 1.13-1.90), living more than 26 miles from Boston (OR 1.46, 95% CI = 1.25-1.71), and initial presentation with a lump found by the patient herself (OR = 2.89, 95% CI = 2.36-3.55) or another breast symptom (OR = 0.25, 95% CI = 1.79-2.82) compared to an abnormal mammogram were significantly associated with a delay in diagnosis. In contrast, the odds of a delay were lower for women who were older than 18-39 years of age and for women living with two or more household members (OR = 0.72, 95% CI = 0.59-0.87). The likelihood of experiencing a delayed breast cancer diagnosis increased markedly if a woman had multiple risk factors, with a nearly 12-fold increase among women with five or more risk factors (OR = 11.96, 95% CI = 6.32-22.61). CONCLUSIONS Younger age, minority race, and self-identification of breast symptom affect the likelihood of delayed breast cancer diagnosis. Awareness of these issues could help focus efforts to develop algorithms that identify women at risk for a delay and build programs that facilitate their timely access to care.

Racial/Ethnic disparities in patient experience with communication in hospitals: real differences or measurement errors?

Background:An important aspect of medical care is clear and effective communication, which can be particularly challenging for individuals based on race/ethnicity. Quality of communication is measured systematically in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, and analyzed frequently such as in the National Healthcare Disparities Report. Caution is needed to discern differences in communication quality from racial/ethnic differences in perceptions about concepts or expectations about their fulfillment. Objectives:To examine assumptions about the degree of commonality across racial/ethnic groups in their perceptions and expectations, and to investigate the validity of conclusions regarding racial/ethnic differences in communication quality. Methods:We used 2007 HCAHPS data from the National CAHPS Benchmarking Database to construct racial/ethnic samples that controlled for other patient characteristics (828 per group). Using multiple-groups confirmatory factor analyses, we tested whether the factor structure and model parameters (ie, factor loadings, intercepts) differed across groups. Results:We identified support for basic tests of equivalence across 7 racial/ethnic groups in terms of equivalent factor structure and loadings. Even stronger support was found for Communication with Doctors and Nurses. However, potentially important nonequivalence was found for Communication about Medicines, including instances of statistically significant differences between non-Hispanic whites and non-Hispanic blacks, Asians, and Native Hawaiian/other Pacific Islanders. Conclusions:Our results provide strongest support for racial/ethnic comparisons on Communication with Nurses and Doctors, and reason to caution against comparisons on Communication about Medicines due to significant differences in model parameters across groups; that is, a lack of invariance in the intercept.

What constitutes patient safety culture in Chinese hospitals

OBJECTIVE To develop a patient safety culture instrument for use in Chinese hospitals, we assessed the appropriateness of existing safety culture questionnaires used in the USA and Japan for Chinese respondents and identified new items and domains suitable to Chinese hospitals. DESIGN Focus group study. SETTING AND PARTICIPANTS Twenty-four physicians, nurses and other health-care workers from 11 hospitals in three Chinese cities. METHODS Three focus groups were conducted in 2010 to elicit information from hospital workers about their perceptions of the appropriateness and importance of each of 97 questionnaire items, derived from a literature review and an expert panel, characterizing hospital safety culture. RESULTS PARTICIPANTS understood the concepts of patient safety and safety culture and identified features associated with safe care. They judged that numerous questions from existing surveys were inappropriate, including 39 items that were dropped because they were judged unimportant, semantically redundant, confusing, ambiguous or inapplicable in Chinese settings. Participants endorsed eight new items and three additional dimensions addressing staff training, mentoring of new hires, compliance with rules and procedures, equipment availability and leadership walk-rounds they judged appropriate to assessing safety culture in Chinese hospitals. This process resulted in a 66-item instrument for testing in cognitive interviews, the next stage of survey development. CONCLUSIONS Focus group participants provided important insights into the refinement of existing items and the construction of new items for measuring patient safety culture in Chinese hospitals. This is a necessary first step in producing a culturally appropriate instrument applicable to specific local contexts.

Development of a patient safety climate survey for Chinese hospitals: cross-national adaptation and psychometric evaluation

Background Existing patient safety climate instruments, most of which have been developed in the USA, may not accurately reflect the conditions in the healthcare systems of other countries. Objectives To develop and evaluate a patient safety climate instrument for healthcare workers in Chinese hospitals. Methods Based on a review of existing instruments, expert panel review, focus groups and cognitive interviews, we developed items relevant to patient safety climate in Chinese hospitals. The draft instrument was distributed to 1700 hospital workers from 54 units in six hospitals in five Chinese cities between July and October 2011, and 1464 completed surveys were received. We performed exploratory and confirmatory factor analyses and estimated internal consistency reliability, within-unit agreement, between-unit variation, unit-mean reliability, correlation between multi-item composites, and association between the composites and two single items of perceived safety. Results The final instrument included 34 items organised into nine composites: institutional commitment to safety, unit management support for safety, organisational learning, safety system, adequacy of safety arrangements, error reporting, communication and peer support, teamwork and staffing. All composites had acceptable unit-mean reliabilities (≥0.74) and within-unit agreement (Rwg ≥0.71), and exhibited significant between-unit variation with intraclass correlation coefficients ranging from 9% to 21%. Internal consistency reliabilities ranged from 0.59 to 0.88 and were ≥0.70 for eight of the nine composites. Correlations between composites ranged from 0.27 to 0.73. All composites were positively and significantly associated with the two perceived safety items. Conclusions The Chinese Hospital Survey on Patient Safety Climate demonstrates adequate dimensionality, reliability and validity. The integration of qualitative and quantitative methods is essential to produce an instrument that is culturally appropriate for Chinese hospitals.

Patient perspectives of care and process and outcome quality measures for heart failure admissions in US hospitals: how are they related in the era of public reporting?

IMPORTANCE Process quality measure performance has improved significantly with public reporting, requiring reevaluation of process-outcome relationships and the emerging role of patient perspectives on care. OBJECTIVE To evaluate associations between heart failure patient perspectives of care and publicly reported processes and outcomes. DESIGN Cross-sectional study, July 2008-June 2011. SETTING US hospitals in the Press Ganey database. PARTICIPANTS Heart failure inpatients. MEASURES Outcomes were Hospital Compare hospital-level risk-adjusted 30-day heart failure mortality and readmissions. Predictors included Hospital Compare heart failure processes of care, a weighted process composite and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) domains for heart failure. Hospital characteristics included volume of heart failure patients and race, health status and education. RESULTS Among 895 included hospitals, performance on process measures was high (median by hospital for composite, 95.6%); the median HCAHPS overall rating was 86.9. Median mortality was 11.3% and readmissions was 24.8%. No process measures were statistically significantly associated with lower mortality or readmissions in adjusted analyses. Higher ratings on HCAHPS patient perspectives of care were significantly correlated with lower readmissions in adjusted analyses, particularly those publicly reported domains conceptually related to readmissions. The magnitude was small (1.8 points higher on a 100-point scale between the highest and lowest quartiles of hospital readmissions). CONCLUSIONS Publicly reported process quality measures were no longer associated with outcomes, but higher patient perspectives of care were associated with lower heart failure readmissions. These associations support continued reevaluation of these measures and increased emphasis on patient experience and outcomes, as planned for Value-Based Purchasing.

A longitudinal study of pain variability and its correlates in ambulatory patients with advanced stage cancer

Although pain is common among patients with advanced cancer, little is known about longitudinal variability in pain intensity. For this report, the authors examined variability in pain intensity over 24 months among ambulatory patients with advanced stage cancers, associations between patient characteristics and within‐patient pain variability, and the relation of pain variability to overall survival.