IN the past several decades, the philosophy of medical practice has been shifted to focus on the values-based practice. The decisions in medicine are increasingly complex than ever due to advance of medical technology and new therapeutic availabilities. Physicians need to take clinical governance, practice quality assurance, and cost-effectiveness into the consideration to care for patients. The practice model has also been shifted from volume-based to value-based services. A value-based service is provided around most common co-occurring medical conditions and complications. It requires an integrative care unit with a dedicated team that devote a significant portion of their time to the medical condition with a physician team captain and a care manager overseeing each patient’s care process. The dedicated team accepts joint accountability for outcomes and costs.
Cancer has become a chronic disease, and it is costly and time-consuming for patients. In the United States (US), value-based practice is a new transformational healthcare delivery model in which hospitals and physicians are reimbursed based on patient health outcomes and rewarded for helping patients improve their health, reduce the effects and incidence of chronic disease. More public health research data shows the benefits of a value-based practice to all stakeholders, including patients and their family, medical institutes, payers, suppliers, as well as society.
Two important components, cancer rehabilitation and palliative care, have been recognized in recent years and valued to improve the overall outcomes for cancer patients. These two services extend from helping recovery from cancer treatment to the end-of-life care (EOLC). They add value for the full cycle of care in clinic setting. These two specialties share common goals to improve patients’ quality of life by improving the levels of functioning and comforts in daily life. They both focus on better managing cancer-related symptoms or cancer treatment-related side effects,1 improving quality of life of patients and families, valuing patient and family preferences and sharing decision-making process. They also aim to improve medical care efficiencies2 and minimize costs. Even the goals of these two services are often aligned, nevertheless, different specialized skills and approaches are used in the care of patients through the disease stages. Cancer rehabilitation emphasizes short- and long-term solutions of improvement in functioning,3 while palliative care focuses specifically on improving immediate quality of life (QOL) in cancer patients that related to physical, psychological, and family distress.4
This article describes roles of cancer rehabilitation and palliative care, highlights how the individual service can contribute to an integrative care process and complement one another to the quality of care services.
Importance of cancer rehabilitation and palliative care
With the advanced medical technology, there are growing number of adult and childhood cancer survivors who have been living with the disease and the treatment-related side effects for many years.5 Most of them often live with multiple chronic symptoms that can be disabling, medically complex and even life-threatening if not well managed in long follow up phases.
In traditional sense, rehabilitation focuses on reducing the level of disability associated with impairments, such as motor deficits associated with paraplegia. This condition can be managed through assisting via an appropriate wheelchair, training, and use of assistive devices for handling daily living activities. Early 1980, benefits of rehabilitation services for cancer patients were not recognized, therefore, little of the rehabilitation services were designed and available to cancer patients. Issues existed in multiple layers including inadequate professional education and awareness trainings, problems with financing cost of care, etc. Until 1990s, more research data suggests that the conventional rehabilitation is effective in managing cancer related functional impacts. Marciniak and associates at Northwestern University studied patients admitted to a rehabilitation hospital because of functional loss related to cancer or its treatment over a two-year period. The data showed rehabilitation interventions were effective in gaining the functions for all subgroup patients between admission and discharge.6
Disability in cancer patients often results from disease and treatment related complications, such as deconditioning, neurologic and musculoskeletal complications. In clinic, the most common symptoms seen in cancer patients can range from fatigue, pain, weakness, dyspnea, nausea, vomiting, being anxious, depression, and delirium.2 Almost 74% of patients who were under chemotherapy stated fatigue or some degree of “lack of energy”, which would not be recovered by bed rest. Pain was the fourth most common symptom, with an overall prevalence of 63%. Other symptoms occurring in more than 50% of patients may include feeling sad or nervous, drowsiness, and difficulty in sleeping. In another study on patients with pancreatic cancer, 82% reported pain.7 For late stage cancer patients, the prevalence of those symptoms is even higher. Furthermore, late stage cancer patients have more serious physical limitations because of cancer progression, bed rest, and treatment related consequences. In these patients, unable to recognize the issues and inadequate symptom control can have a major functional and psychosocial impact, causing significant distress and impairing quality of life.
The palliative care and hospice movement have been incredibly grown in US in the past two decades. One of reasons is that the Medicare, the largest medical plan in US, is influential in the field because a larger number of beneficiaries are elderly patients. The palliative care services have been mostly utilized in the elderly patients with late stage chronical disease and whose life span is within 6 months. There are mounting evidence that in patients with advanced cancer, palliative care benefits quality of life and even survivals.8 From perspective of full cycle of care, palliative care and hospice services have demonstrated value and meet the needs for the end of life care.
Understanding the scope of cancer rehabilitation
Cancer rehabilitation is a complex care program and need multidiscipline team led by specialists. It has focused on to restore the function after cancer therapy to the premorbid status and maintaining patients’ function during length of cancer therapy.
Cancer patients often experience many concurrent impairments depending on primary diseases, disease progression as well as the subsequent treatment plans. The complexity of the impairment presentation can be overwhelming for oncologists or the oncology team who are not generally trained to diagnose and treat these issues. Therefore, conventional interdisciplinary model for cancer rehabilitation care is to address those complex disabilities.
One of common example is that the rehabilitation team play a major role in the management of cancer fatigue. Most cancer patients have experienced various degrees of fatigue throughout the course of treatments and the disease. It is one of the most distressing problems affecting patients and need to be well managed by rehabilitation team based on the individual patient’s condition and coordinate the rehabilitation schedules based on the patient treatment plan.9 Physical therapy and occupational therapy play important roles in helping patients to perform appropriate therapeutic exercise, coaching energy conservation techniques, assisting patients to handle the daily activities, and monitoring any new sign of disease development as well.10,11
One of common misunderstandings in the scopes of cancer rehabilitation is the confusion with exercise programs, which do not address the range of impairments that cancer patients encounter. An exercise-only based model 12 of cancer rehabilitation does not support the various cancer diagnosis or treatment related issues, such as speech, swallowing impairments in head and neck cancer patients induced by surgery and radiation therapy, or cognitive impairments in primary or metastatic brain cancer, or surgical and radiation treatment related lymphedema in breast cancer, genital caner or head and neck cancer patients. It is important for healthcare professional to recognize that while exercise is a key component of the conventional rehabilitation model, it does not represent the totality of the services provided to cancer patients.
Understanding the scope of palliative and hospice care
Palliative care has been defined by The World Health Organization as an approach “that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and assessment and treatment of pain and other problems, physical, psychosocial and spiritual”.13 Palliative care focuses on the management of pain as well as psychologic, social, and spiritual problems that interfere with quality of life for advanced cancer patients. Although significant differences in practice patterns may exist depending upon the actual service line available for various institutes,14 palliative care in oncology settings often is referred as a consultation service. When terminal ill patients are exhausted with all available treatment options, oncologist most likely will refer patients to hospice services for the end of life care. More hospice services are provided at home care settings in recent years.
Since last two decades, palliative care consultation services have been increasingly implemented in the American health care system,15 and more practice data has showed the improved patient experience in community-based care setting, the benefits of palliative care in terms of QOL, economic, and outcomes.16-18
Early introducing palliative care to cancer patients and families is an important part of patient education. Using layman language to clearly communicate with patients and family regarding the benefits of palliative care is essential to improve patient and family’s understanding. There are also needs to promote palliative care education in professional colleagues to minimize service confusion, to help for better understanding and acceptance, and to promote patient referral. Despite evidence consistently demonstrating its benefits to QOL in patients,8 palliative care is still widely misunderstood not only by oncologists but also by patients and families.
Integrative cancer coordination care: a value-based practice moving forward
To establish a high-quality cancer care service, oncology teams need to work with cancer rehabilitation or palliative care teams to help co-manage these complex or refractory symptoms. Rehabilitation clinicians may treat patients aiming at a cure of the underlying neurologic or musculoskeletal condition. Palliative care referral is often triggered by patients’ high symptom burden or metastatic disease, with approach focusing on symptom control instead of curing the illness. Most patients will need parallel services which encompass a multidisciplinary team involvement to implement the care plan. It is a particular truth when disease recurrence and at the end of life. In advanced cancer patients, using rehabilitation techniques for palliating purpose may still prevent from a decline, or even improve functions in activities of daily living, and help in pain relief and endurance.19 The bed side physical therapy has been shown to be a feasible approach even for terminally ill patients as well.20 There were evidences showing that even limited rehabilitation services would provide benefits in a hospice for individuals with advanced, recurrent, or progressive disease. The study also showed that there was reduced need for health service resources with improvement in QOL of patient as well as for caregivers.21
Many barriers exist in the real-world practices to integrate and coordinate both services into cancer care service lines. It is important to recognize those barriers and implement strategies to overcome them.
One of the obstacles is that rehabilitation professionals perceived lack of experience in caring medically complex cancer patients and lack of knowledge in the development of new technologies that have been rapidly evolving and have significant impacts on the diagnosis of symptom burden and associated impairments.22 On the other hand, oncology team, including those in palliative care, may not understand the many different ways rehabilitation team can help for these patients and may not have experience in screening these patients for their rehabilitation needs.23 In the US, there are still challenges to expand the service of palliative care, such as physician resistance, unrealistic expectations from patients and families, lack of educations and workforce, and issues exist in society awareness, government policy and financial reimbursement.
Currently, there is no single universally recognized model that is “one size fit all “regarding the coordinate care setting up. Improving integrative services demand a comprehensive strategy from medical institutes’ inputs, government policy support, insurance reimbursement as well as the participation of advocacy organizations. More interdisciplinary collaboration on various practice settings, such as community base practice or home care service model needs to be tested before translating the pilot practice data into the clinical care system. The multiple specialties collaboration is needed in order to foster meaningful change in patient care models. Advocacy initiatives like the Patient Quality of Life Coalition in US 24 that bring together stakeholders across disciplines provide a helpful coordinating infrastructure and framework to help advance of these opportunities. There are many impacts assessment project ongoing currently in various reginal settings 25-27 in order to support healthcare reform and policy amendments.
As for Chinese medical society, the concepts of those two services are relatively new not only for medical professionals but also for publics to recognize and accept. There are much more barriers to incorporate these two services in the current Chinese healthcare delivery system. Chinese physicians not only face implementation obstacles at institutional level, the lack of trained professionals, misunderstanding from professionals and rejections from publics, but also challenged by lack of support from government for policy and finance aspects. With China current health policy debates, the major impact is to tie with the fiscal budget reimbursement. In this business sector with extremely narrow profit margins or sole dependence of government reimbursement or charity support for both services, scanty fiscal support could worsen the already existing access problems for many patients.
One of feasible approach is to initiate multiple pilot programs in various regions or clinic settings to identify the opportunities and the challenges in integrating two services into the current health care structures. The health economic data from those pilot programs shall present to the decision-making groups in government, help to reevaluate health economic policy and to reform the national health care budget. Only with appropriate revision of medical service fees for cancer rehabilitation and palliative care, Chinese medical society may further propel interest in these topics and reforms.
From clinic professional level, the emerging movements of professional organizations in China have raised the awareness of improving quality of life in cancer patients and provided entry level knowledge base training for oncologists. These efforts will increase awareness of professionals screening and identifying the issues such as disease burden and treatment related impairments in oncology patients. There is an urgent need for Chinese oncology society to implement appropriate training programs for professionals and enable oncologists to screen patients appropriately. Timely use of screening protocol is a way to improve the care coordination. Screening can begin at the time of diagnosis and continue throughout treatment and survivorship. Ideally, with the baseline and follow up assessments, the oncology team can proactively identify needs and help appropriate referrals to rehabilitation and palliative care services. This kind of screen protocol has been implemented for breast cancer population with good outcomes in US. The goals of screening are to capture symptoms earlier, possibly reducing symptom burden and improve outcomes. Ultimately, oncologists can use the assessments to recommend for rehabilitation services and palliative caregiver at the moment. All those efforts should be considered to integrate into a patient’s survivorship care plan.28
There is a proven market for these two services, but growth is limited by multilayer problems in China. One of the issues is lack of qualified rehabilitation and palliative physicians, therapists, nurses to provide services. Currently, China has large gaps even for the entry level training in the two specialties. The standardized, structured educational opportunities and credentialing in program, such as residencies and certification, shall be developed at national level for cancer rehabilitation medicine and palliative medicine.
With the challenging goals of lowering healthcare costs while improving patient outcomes and satisfaction with care in global healthcare environment, the potential synergism of integrating rehabilitation and palliative care services in oncology practice will require intensification of interdisciplinary dialogue. Nevertheless, more evidence-based researches and cost-benefit health economic researches are also urgently needed to provide data support for medical resource allocation and appropriate service fee revision. From government health policy perspective, public policies shall be reevaluated to address the regulation reform of payment and reimbursement, modernization of legislation for access and referrals to these two services, institutional support of education for key stakeholders, and to increase funding for support of rehabilitation and palliative care team early involvement in the cancer patient care plans.
Conflict of interests statement
The author has no conflict of interests disclosed.
参考文献
Common symptoms in patients with advanced cancer
The goal of this study was to identify the symptoms of patients with . One hundred consecutive patients referred to the Palliative Care Service at the Cleveland Clinic Foundation were studied using a standard tool that included questions on 38 specific symptoms. The most common symptoms were pain, weight loss, and anorexia. Significant findings also included that women had more frequent and severe gastrointestinal complaints than men. These do not appear to be related to specific primary sites.
The symptoms of advanced cancer
The incidence and mortality of are increasing. In when cure is impossible, symptoms should be the focus of attention. We review our recent prospective studies on symptom prevalence and severity in 1,000 patients with . patients are polysymptomatic. Symptom prevalence differs with age, gender, and site. The pattern of gastrointestinal symptoms is related to gender and severe weight loss. Specific symptoms are associated with reduced survival. There is a gender difference in survival favoring females. Pain, easy fatigue, and anorexia are consistently among the 10 most prevalent symptoms at all 17 primary sites. When pain, anorexia, weakness, anxiety, lack of energy, easy fatigue, early satiety, constipation, and dyspnea were present, 60% to 80% of patients rated them as moderate or severe, ie, of clinical importance. The most common symptoms also are the most severe. In general, the same symptoms are clinically important at most primary sites.
The future of physiatry: with challenges come opportunities
Mukai A.
Conceptual models for integrating palliative care at cancer centers
Abstract Palliative care programs are rapidly evolving in acute care facilities. Increased and earlier access has been advocated for patients with life-threatening illnesses. Existing programs would need major growth to accommodate the increased utilization. The objective of this review is to provide an update on the current structures, processes, and outcomes of the Supportive and Palliative Care Program at the University of Texas M.D. Anderson Cancer Center (UTMDACC), and to use the update as a platform to discuss the challenges and opportunities in integrating palliative and supportive services in a tertiary care cancer center. Our interprofessional program consists of a mobile consultation team, an acute palliative care unit, and an outpatient supportive care clinic. We will discuss various metrics including symptom outcomes, quality of end-of-life care, program growth, and financial issues. Despite the growing evidence to support early palliative care involvement, referral to palliative care remains heterogeneous and delayed. To address this issue, we will discuss various conceptual models and practical recommendations to optimize palliative care access.
Committee on Improving the Quality of Cancer Care: Addressing the Challenges of an Aging Population; Board on Health Care Services; Institute of Medicine
Functional outcome following rehabilitation of the cancer patient
Abstract OBJECTIVE: To identify impairments resulting from cancer or its treatment in patients undergoing inpatient rehabilitation, to assess the extent of functional gains, and to determine if cancer type, ongoing radiation treatment, or the presence of metastatic disease influences functional improvement. DESIGN AND SETTING: A retrospective, case series of cancer patients undergoing inpatient rehabilitation at a free-standing, university-affiliated rehabilitation hospital. PARTICIPANTS: A referred sample of 159 patients admitted because of functional impairments resulting from cancer or its treatment during a 2-year time period. INTERVENTION: Comprehensive inpatient rehabilitation. MAIN OUTCOME MEASURE: Functional status as measured by the motor score of the Functional Independence Measure. RESULTS: Significant functional gains were made between admission (mean = 42.9) and discharge (mean = 56.0; p < .001), with all cancer subgroups making similar gains. The presence of metastatic disease did not influence functional outcome, and those patients receiving radiation actually made larger functional improvements (p = .025). CONCLUSION: Individuals impaired by cancer or its treatment benefit from inpatient rehabilitation. The presence of metastatic disease or ongoing radiation should not preclude participation.
Physical activity and rehabilitation programs should be recommended on palliative care for patients with cancer
The author reflects on the importance of rehabilitation and physical therapy programs in the palliative care of cancer patients. He claims that such programs are disregarded in hospice and palliative care programs. He says that physical activities have several beneficial effects such as increased cardiovascular capacity and quality of life (QOL) and decrease in fatigue and sleep disorders. He notes that most patients prefer doing physical activities after the completion of their treatment.
Early specialty palliative care—translating data in oncology into practice
http://www.nejm.org/doi/abs/10.1056/NEJMsb1305469
Cancer-related fatigue—mechanisms, risk factors, and treatments
Fatigue is one of the most common adverse effects of cancer that might persist for years after treatment completion in otherwise healthy survivors. Cancer-related fatigue causes disruption in all aspects of quality of life and might be a risk factor of reduced survival. The prevalence and course of fatigue in patients with cancer have been well characterized and there is growing understanding of the underlying biological mechanisms. Inflammation seems to have a key role in fatigue before, during, and after cancer-treatment. However, there is a considerable variability in the presentation of cancer-related fatigue, much of which is not explained by disease-related or treatment-related characteristics, suggesting that host factors might be important in the development and persistence of this symptom. Indeed, longitudinal studies have identified genetic, biological, psychosocial, and behavioural risk factors associated with cancer-related fatigue. Although no current gold-standard treatment for fatigue is available, a variety of intervention approaches have shown beneficial effects in randomized controlled trials, including physical activity, psychosocial, mind-body, and pharmacological treatments. This Review describes the mechanisms, risk factors, and possible interventions for cancer-related fatigue, focusing on recent longitudinal studies and randomized trials that have targeted fatigued patients.
A pilot study examining energy conservation for cancer treatment-related fatigue
Abstract The purpose of this pilot study was to examine the feasibility of conducting an energy conservation and activity management (ECAM) intervention for cancer treatment-related fatigue and describe patterns of cancer treatment-related fatigue for two groups undergoing active treatment, one receiving the ECAM intervention and a nonequivalent control group receiving standard care for cancer treatment-related fatigue. The ECAM group received 3 telephone sessions focusing on the provision of information about fatigue, development of an energy conservation plan, and evaluation of the plan's effectiveness. Data for the ECAM group were collected before treatment, at an expected fatigue high point during treatment, and an expected low point of fatigue after treatment. The nonequivalent control group lacked the pretreatment measure but had equivalent follow-up measurement points. The feasibility of conducting the ECAM intervention was supported by patient adherence in receiving all 3 sessions of the intervention and by their self-reports of its usefulness and plans to continue using ECAM skills. Patterns of fatigue differed for the ECAM study group and the nonequivalent control group, suggesting that the intervention moderates the expected rise in fatigue due to cancer therapy. A full-scale clinical trial is needed to evaluate the efficacy of the ECAM intervention.
Exercise-based oncology rehabilitation: leveraging the cardiac rehabilitation model
Association between a name change from palliative to supportive care and the timing of patient referrals at a comprehensive cancer center
Palliative care consultation services are now available in the majority of cancer centers, yet most referrals to palliative care occur late. We previously found that the term "palliative care" was perceived by oncology professionals as a barrier to early patient referral. We aimed to determine whether a service name change to supportive care was associated with earlier referrals.Records of 4,701 consecutive patients with a first palliative care consultation before (January 2006 to August 2007) and after (January 2008 to August 2009) the name change were analyzed, including demographics and dates of first registration to hospital, advanced cancer diagnosis, palliative care consultation, and death. One-sample proportions tests, median tests, (2) tests, and log-rank tests were used to identify group differences.The median age was 59 years, 50% were male, and 90% had solid tumors. After the name change, we found: (a) a 41% greater number of palliative care consultations (1,950 versus 2,751 patients; p < .001), mainly as a result of a rise in inpatient referrals (733 versus 1,451 patients; p < .001), and (b) in the outpatient setting, a shorter duration from hospital registration to palliative care consultation (median, 9.2 months versus 13.2 months; hazard ratio [HR], 0.85; p < .001) and from advanced cancer diagnosis to palliative care consultation (5.2 months versus 6.9 months; HR, 0.82; p < .001), and a longer overall survival duration from palliative care consultation (median 6.2 months versus 4.7 months; HR, 1.21; p < .001).The name change to supportive care was associated with more inpatient referrals and earlier referrals in the outpatient setting. The outpatient setting facilitates earlier access to supportive/palliative care and should be established in more centers.
America’s care of serious illness: a state-by-state report card on access to palliative care in our nation’s hospitals
Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care
Impact of an inpatient palliative care team: a randomized control trial
Background: Palliative care improves care and reduces costs for hospitalized patients with life-limiting illnesses. There have been no multicenter randomized trials examining impact on patient satisfaction, clinical outcomes, and subsequent health care costs. Objective: Measure the impact of an interdisciplinary palliative care service (IPCS) on patient satisfaction, clinical outcomes, and cost of care for 6 months posthospital discharge. Methods: Multicenter, randomized, controlled trial. IPCS provided consultative, interdisciplinary, palliative care to intervention patients. Controls received usual hospital care (UC). Setting and sample: Five hundred seventeen patients with life-limiting illnesses from a hospital in Denver, Portland, and San Francisco enrolled June 2002 to December 2003. Measures: Modified City of Hope Patient Questionnaire, total health care costs, hospice utilization, and survival. Results: IPCS reported higher scores for the Care Experience scale (IPCS: 6.9 versus UC: 6.6, p 0.04) and for the Doctors, Nurses/Other Care Providers Communication scale (IPCS: 8.3 versus UC: 7.5, p 0.0004). IPCS patients had fewer intensive care admissions (ICU) on hospital readmission (12 versus 21, p 0.04), and lower 6-month net cost savings of 4,855 per patient ( p 0.001). IPCS had longer median hospice stays (24 days versus 12 days, p 0.04). There were no differences in survival or symptom control. Conclusions: IPCS patients reported greater satisfaction with their care experience and providers' communication, had fewer ICU admissions on readmission, and lower total health care costs following hospital discharge.
Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the project ENABLE II randomized controlled trial
The benefits of rehabilitation for palliative care patients
URL
PMID:19910723820524301083
Palliative care requires an interdisciplinary team approach to provide the best care for patients with life-threatening illnesses. Like palliative medicine, rehabilitation also uses an interdisciplinary approach to treating patients with . This review article focuses on rehabilitation interventions that can be beneficial in patients with late stage illnesses. Rehabilitation may be useful in improving the quality of life by palliating function, mobility, activities of daily living, pain relief, endurance, and the psyche of a patient while helping to maintain as much independence as possible, leading to a decrease in burden on caregivers and family. Rehabilitative services are underutilized in the palliative care setting, and more research is needed to address how patients may benefit as they approach the end of their lives.
Physical exercise and therapy in terminally ill cancer patients: a retrospective feasibility analysis
Purpose Physical exercise (PE) and/or therapy (PT) shows beneficial effects in advanced cancer patients and is increasingly implemented in hospice and palliative care, although systematic data are rare. This retrospective study systematically evaluated the feasibility of PE/PT in terminally ill cancer patients and of different modalities in correspondence to socio-demographic and disease- and care-related aspects. Methods All consecutive terminally ill cancer patients treated in a palliative care inpatient ward during a 3.5-year period were included. The modalities were chosen according to the therapists' and patients' appraisal of current performance status and symptoms. Results PE/PT were offered to 572 terminally ill cancer patients, whereof 528 patients (9202%) were able to perform at least one PE/PT unit (average 4.2 units/patient). The most frequently feasible modalities were physical exercises in 5002%, relaxation therapy in 2202%, breathing training in 1002%, and positioning and lymph edema treatment in 602% each. Physical exercise and positioning treatment were performed significantly more often in older patients ( p 65=650.009 and p 65=650.022, respectively), while relaxation ( p 65=650.05) and lymph edema treatment ( p 65=650.001) were used more frequently in younger. Breathing training was most frequently performed in head and neck cancer ( p 65=650.002) and lung cancer ( p 65=650.026), positioning treatment in brain tumor patients ( p 65=650.021), and lymph edema treatment in sarcoma patients ( p 65=650.012). Conclusions PE/PT were feasible in >9002% of terminally ill cancer patients to whom PE/PT had been offered. Physical exercises, relaxation therapy, and breathing training were the most frequently applicable methods. Prospective trials are needed to evaluate the efficacy of specific PE/PT programs in terminally ill cancer patients.
Rehabilitation in advanced,progressive, recurrent cancer: a randomized controlled trial
Two million people across the U.K. are living with cancer, often experienced as a long-term condition. They may have unmet needs after active treatment. Rehabilitation aims to address these needs, maximize psychological and physical function, and enable minimum dependency regardless of life expectancy. We aimed to test, in a randomized controlled trial, the clinical and cost effectiveness of a rehabilitation intervention for patients with advanced, recurrent cancer. We conducted a two-arm, wait-list control, randomized trial of a complex rehabilitation intervention delivered by a hospice-based multidisciplinary team vs. usual care for active, progressive, recurrent hematological and breast malignancies, with a follow-up at three months. The primary outcome was the psychological subscale of the Supportive Care Needs Survey (SCNS). Secondary outcomes were other domains of the SCNS, psychological status, continuity of care, quality of life, and resource use. Forty-one participants were enrolled and 36 completed the trial. The primary outcome was significantly lower in the intervention arm (adjusted difference 6116.8, 95% CI 6128.34 to 615.3; P02=020.006). The SCNS physical and patient care subscales (6114.2, 95% CI 6126.2 to 612.2; P02=020.02 and 617.4, 95% CI 6113.7 to 611.1; P02=020.02, respectively) and self-reported health state (12.8, 95% CI 3.2 to 22.4; P02=020.01) also differed significantly. The incremental cost-effectiveness ratio was 0519,390 per quality-adjusted life year. This intervention significantly reduced the unmet needs of cancer survivors and it is likely that it is cost-effective. Despite small numbers, the main effect size was robust. We recommend implementation alongside evaluation in02wider clinical settings and patient populations.
Cancer rehabilitation education during physical medicine and rehabilitation residency: preliminary data regarding the quality and quantity of experiences
An abstract is unavailable.
Oncology and physical medicine and rehabilitation
Cancer patients are living longer with deficiencies and functional impairments requiring often typically a care in physical medicine and rehabilitation (PMR). To examine the care of cancer patients in PMR. Investigation made with a questionnaire diffused from the e-mail listing of the Société Fran04aise de Médecine Physique et de Réadaptation. Sixty-seven answers received. Fifty-seven centers take care of cancer patients. On average, 4% of cancer patients are hospitalised in PMR. Spinal cord injuries and hemiplegias are the most common impairments. Forty-two percent of the PMR units take the patients in all the stages of cancer treatment. Working relationships between PMR and oncology units are formalized only eight times out of 52. In case of health degradation, relationships with a palliative care unit are frequent but not generalized. Eighty-five percent of the centers think that PMR is not enough developed in oncology. In spite of its limited character, this investigation shows that the PMR units take these patients. Situations where PMR has an important role in the follow-up of cancer patients are multiple and publications have showed its interest, especially on the limitations of activities. It is important to make better known the interest of PMR in oncology units but also to develop specific care within PMR units.
An action plan for translating cancer survivorship research into care
Abstract To meet the complex needs of a growing number of cancer survivors, it is essential to accelerate the translation of survivorship research into evidence-based interventions and, as appropriate, recommendations for care that may be implemented in a wide variety of settings. Current progress in translating research into care is stymied, with results of many studies un- or underutilized. To better understand this problem and identify strategies to encourage the translation of survivorship research findings into practice, four agencies (American Cancer Society, Centers for Disease Control and Prevention, LIVE STRONG: Foundation, National Cancer Institute) hosted a meeting in June, 2012, titled: "Biennial Cancer Survivorship Research Conference: Translating Science to Care." Meeting participants concluded that accelerating science into care will require a coordinated, collaborative effort by individuals from diverse settings, including researchers and clinicians, survivors and families, public health professionals, and policy makers. This commentary describes an approach stemming from that meeting to facilitate translating research into care by changing the process of conducting research-improving communication, collaboration, evaluation, and feedback through true and ongoing partnerships. We apply the T0-T4 translational process model to survivorship research and provide illustrations of its use. The resultant framework is intended to orient stakeholders to the role of their work in the translational process and facilitate the transdisciplinary collaboration needed to translate basic discoveries into best practices regarding clinical care, self-care/management, and community programs for cancer survivors. Finally, we discuss barriers to implementing translational survivorship science identified at the meeting, along with future directions to accelerate this process. Published by Oxford University Press 2014.
The economic and clinical impact of an inpatient palliative care consultation service: a multifaceted approach
While there has been a rapid increase of inpatient palliative care (PC) programs, the financial and clinical benefits have not been well established. Determine the effect of an inpatient PC consultation service on costs and clinical outcomes. Multifaceted study included: (1) interrupted time-series design utilizing mean daily costs preintervention and postintervention; (2) matched cohort analysis comparing PC to usual care patients; and (3) analysis of symptom control after consultation. Large private, not-for-profit, academic medical center in San Francisco, California, 2004-2006. Time series analysis included 282 PC patients; matched cohorts included 27 PC with 128 usual care patients; clinical outcome analysis of 48 PC patients. Mean daily patient costs and length of stay (LOS); pain, dyspnea, and secretions assessment scores. Mean daily costs were reduced 33% (p < 0.01) from preintervention to postintervention period. Mean length of stay (LOS) was reduced 30%. Mean daily costs for PC patients were 14.5% lower compared to usual care patients (p < 0.01). Pain, dyspnea, and secretions scores were reduced by 86%, 64%, and 87%, respectively. Over the study period, time to PC referral as well as overall ALOS were reduced by 50%. The large reduction in mean daily costs and LOS resulted in an estimated annual savings of $2.2 million in the study hospital. Our results extend the evidence base of financial and clinical benefits associated with inpatient PC programs. We recommend additional study of best practices for identifying patients and providing consultation services, in addition to progressive management support and reimbursement policy.
A cost-utility analysis of a rehabilitation service for people living with and beyond cancer
Background We conducted a wait-list control randomised trial of an outpatient rehabilitation service for people living with and beyond cancer, delivered in a hospice day care unit. We report the results of an economic evaluation undertaken using the trial data. Methods Forty-one participants were recruited into the study. A within-trial stochastic cost-utility analysis was undertaken using Monte-Carlo simulation. The outcome measure for the economic evaluation was quality adjusted life years (QALYs). Costs were measured from the perspective of the NHS and personal social services. Uncertainty in the observed data was captured through probabilistic sensitivity analysis. Scenario analysis was conducted to explore the effects of changing the way QALYs were estimated and adjusting for baseline difference in the population. We also explore assumptions about the length of treatment benefit being maintained. Results The incremental cost-effectiveness ratio (ICER) for the base-case analysis was ??14,231 per QALY. When QALYs were assumed to change linearly over time, this increased to ??20,514 per QALY at three months. Adjusting the estimate of QALYs to account for differences in the population at baseline increased the ICER to ??94,748 per QALY at three months. Increasing the assumed length of treatment benefit led to reduced ICERs in all scenarios. Conclusions Although the intervention is likely to be cost-effective in some circumstances, there is considerable uncertainty surrounding the decision to implement the service. Further research, informed by a formal value of information analysis, would reduce this uncertainty.
Cancer survivorship: a growing role for physiatric care
Abstract Cancer survivors are growing in number, with an estimated 14.5 million people alive in the United States with a diagnosis of cancer and an expected 19 million by 2024. Many cancer survivors have well-documented medical needs related to the cancer diagnosis and treatment. Survivorship represents a distinct period along the continuum of cancer care and necessitates a unique approach to meet the demands of this patient population. As a result, the Commission on Cancer, a program of the American College of Surgeons, which accredits hospital cancer centers based on established quality standards, is requiring that by 2015 all designated cancer centers have a survivorship care plan in place for patients upon the completion of acute treatment for malignancy.
