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1.
J Multidiscip Healthc ; 9: 267-74, 2016.
Article in English | MEDLINE | ID: mdl-27358568

ABSTRACT

INTRODUCTION: The Institute of Medicine, the American Society of Clinical Oncology, and the European Society of Medical Oncology promote a multidisciplinary approach for the treatment of cancer. Stage III non-small-cell lung cancer (NSCLC) represents a heterogeneous group of diseases necessitating coordination of care among medical, radiation, and surgical oncology. The optimal care of stage III NSCLC underscores the need for a multidisciplinary approach. METHODS: From tumor registry data, we identified all cases of stage III NSCLC seen at Lehigh Valley Health Network between March 2010 and March 2013. The care received by patients when seen in the thoracic multidisciplinary clinic (MDC) was compared with the care received when not seen in the thoracic MDC. RESULTS: All patients seen in the MDC, compared to <50% of patients seen outside the MDC, were evaluated by more than one physician prior to beginning the treatment. Time to initiate treatment was shorter in MDC patients than in non-MDC patients. Patients seen in the MDC had a greater concordance with clinical pathways. A greater percentage of patients seen in the thoracic MDC had pathologic staging of their mediastinum. Patients seen in the MDC were more likely to receive all of their care at Lehigh Valley Health Network. CONCLUSION: Multidisciplinary care is essential in the treatment of patients with stage III NSCLC. Greater utilization of MDCs for this complex group of patients will result in more efficient coordination of care, pretreatment evaluation, and therapy, which in turn should translate to improve patients' outcomes.

2.
Qual Life Res ; 25(11): 2833-2843, 2016 11.
Article in English | MEDLINE | ID: mdl-27338811

ABSTRACT

PURPOSE: Patient experiences with symptom care need to be assessed and documented to ensure successful management of cancer-related symptoms. This paper details one method for creating symptom management quality improvement (SMQI) reports, including case-mix adjustment of patient-reported measures. Qualitative data regarding the acceptability of these reports at participating cancer centers (CCs) are also provided. METHODS: Data were collected from 2226 patients treated at 16 CCs via mailed/Web questionnaires. Twelve items assessing patient perceptions of symptom management-pain, fatigue, emotional distress-served as key quality indicators. Medico-demographic variables suitable for case-mix adjustment were selected using an index score combining predictive power and heterogeneity across CCs. SMQI reports were designed with staff feedback and produced for each CC, providing crude and adjusted CC-specific rates, along with study-wide rates for comparison purposes. RESULTS: Cancer type and participant educational level were selected for case-mix adjustment based upon high index scores. The Kendall rank correlation coefficient showed that case-mix adjustments changed the ranking of CCs on the key quality indicators (% Δ rank range: 5-22 %). The key quality indicators varied across CCs (all p < 0.02). SMQI reports were well received by CC staff, who described plans to share them with key personnel (e.g., cancer committee, navigator). CONCLUSIONS: This paper provides one method for creating hospital-level SMQI reports, including case-mix adjustment. Variation between CCs on key quality indicators, even after adjustment, suggested room for improvement. SMQI reports based on patient-reported data can inform and motivate efforts to improve care through professional/patient education and applying standards of care.


Subject(s)
Patient Reported Outcome Measures , Quality Improvement , Sickness Impact Profile , Aged , Humans , Middle Aged , Quality Indicators, Health Care , Surveys and Questionnaires
3.
Manag Care ; 24(10): 56-64, 2015 Oct.
Article in English | MEDLINE | ID: mdl-26665718

ABSTRACT

INTRODUCTION: The Moffitt Oncology Network (MON) Initiative demonstrates a way to form a value-based network based upon clinical pathways across a broad geographical area. METHODS: Moffitt Cancer Center (MCC) has developed various cancer-specific pathways. MCC pathways translate evidence-based guidelines into personalized cancer treatment and set a care standard for evaluation and personalized treatment. MCC is using these pathways with other hospital systems and physician groups throughout the MON. Clinical Performance and Value Vignettes, which are virtual patient cases related to the specific clinical pathways, are used to improve the uptake of pathways in the MON. We report here on the baseline data of 66 breast cancer care providers who took 132 breast cancer vignettes. Using the vignettes, variation in care practice is examined, with special attention to use of clinical breast cancer pathways. RESULTS: Pathway-based clinical care was measured at baseline across MON sites.The mean distributions at baseline varied across all sites and were not statistically significantly different (P>.05). Scores varied by domain across sites, although history and physical scores tended to be higher than work-up, diagnosis, and treatment scores. Pathway adherence also varied for specific diagnostic evaluations or treatments: surgery; sentinel/axillary lymph node dissection; radiation therapy; chemotherapy; and hormonal therapy, and also for the prevalence of unnecessary testing. CONCLUSION: Our study suggests that fostering the adoption of breast cancer clinical pathways into an oncology network is feasible; however, adherence to pathways in breast cancer is varied and reducing such variation is a priority as oncology networks continue to grow in popularity.


Subject(s)
Critical Pathways , Guideline Adherence , Medical Oncology , Quality Assurance, Health Care , Humans
5.
Sleep ; 38(8): 1229-36, 2015 Aug 01.
Article in English | MEDLINE | ID: mdl-25581921

ABSTRACT

STUDY OBJECTIVES: We tested whether providing adults with obstructive sleep apnea (OSA) with daily Web-based access to their positive airway pressure (PAP) usage over 3 mo with or without a financial incentive in the first week improves adherence and functional outcomes. SETTING: Academic- and community-based sleep centers. PARTICIPANTS: One hundred thirty-eight adults with newly diagnosed OSA starting PAP treatment. INTERVENTIONS: Participants were randomized to: usual care, usual care with access to PAP usage, or usual care with access to PAP usage and a financial incentive. PAP data were transmitted daily by wireless modem from the participants' PAP unit to a website where hours of usage were displayed. Participants in the financial incentive group could earn up to $30/day in the first week for objective PAP use ≥ 4 h/day. MEASUREMENTS AND RESULTS: Mean hours of daily PAP use in the two groups with access to PAP usage data did not differ from each other but was significantly greater than that in the usual care group in the first week and over 3 mo (P < 0.0001). Average daily use (mean ± standard deviation) during the first week of PAP intervention was 4.7 ± 3.3 h in the usual care group, and 5.9 ± 2.5 h and 6.3 ± 2.5 h in the Web access groups with and without financial incentive respectively. Adherence over the 3-mo intervention decreased at a relatively constant rate in all three groups. Functional Outcomes of Sleep Questionnaire change scores at 3 mo improved within each group (P < 0.0001) but change scores of the two groups with Web access to PAP data were not different than those in the control group (P > 0.124). CONCLUSIONS: Positive airway pressure adherence is significantly improved by giving patients Web access to information about their use of the treatment. Inclusion of a financial incentive in the first week had no additive effect in improving adherence.


Subject(s)
Continuous Positive Airway Pressure/statistics & numerical data , Income , Internet , Motivation , Patient Compliance/statistics & numerical data , Sleep Apnea, Obstructive/economics , Sleep Apnea, Obstructive/therapy , Continuous Positive Airway Pressure/economics , Female , Humans , Male , Middle Aged , Patient Compliance/psychology , Polysomnography , Surveys and Questionnaires , Time Factors , Treatment Outcome
6.
J Oncol Pract ; 11(1): e36-43, 2015 01.
Article in English | MEDLINE | ID: mdl-25336082

ABSTRACT

PURPOSE: The National Cancer Institute Community Cancer Centers Program (NCCCP) began in 2007 with a goal of expanding cancer research and delivering quality care in communities. The NCCCP Quality of Care (QoC) Subcommittee was charged with developing and improving the quality of multidisciplinary care. An assessment tool with nine key elements relevant to MDC structure and operations was developed. METHODS: Fourteen NCCCP sites reported multidisciplinary care assessments for lung, breast, and colorectal cancer in June 2010, June 2011, and June 2012 using an online reporting tool. Each site evaluated their level of maturity (level 1 = no multidisciplinary care, level 5 = highly integrated multidisciplinary care) in nine elements integral to multidisciplinary care. Thematic analysis of open-ended qualitative responses was also conducted. RESULTS: The proportion of sites that reported level 3 or greater on the assessment tool was tabulated at each time point. For all tumor types, sites that reached this level increased in six elements: case planning, clinical trials, integration of care coordination, physician engagement, quality improvement, and treatment team integration. Factors that enabled improvement included increasing organizational support, ensuring appropriate physician participation, increasing patient navigation, increasing participation in national quality initiatives, targeting genetics referrals, engaging primary care providers, and integrating clinical trial staff. CONCLUSIONS: Maturation of multidisciplinary care reflected focused work of the NCCCP QoC Subcommittee. Working group efforts in patient navigation, genetics, and physician conditions of participation were evident in improved multidisciplinary care performance for three common malignancies. This work provides a blueprint for health systems that wish to incorporate prospective multidisciplinary care into their cancer programs.


Subject(s)
Breast Neoplasms/therapy , Colorectal Neoplasms/therapy , Community Health Services , Lung Neoplasms/therapy , Quality of Health Care , Cancer Care Facilities , Clinical Trials as Topic/statistics & numerical data , Community Health Services/organization & administration , Community Health Services/standards , Female , Humans , National Cancer Institute (U.S.) , Patient Care Team , United States
7.
Intensive Care Med ; 40(8): 1124-31, 2014 Aug.
Article in English | MEDLINE | ID: mdl-24898893

ABSTRACT

BACKGROUND: Sleepiness and fatigue are commonly reported by family members of intensive care unit (ICU) patients. Sleep deprivation may result in cognitive deficits. Sleep deprivation and cognitive blunting have not been quantitatively assessed in this population. We sought to determine the proportion of family members of ICU patients that experience excessive daytime sleepiness, sleep-associated functional impairment, and cognitive blunting. METHODS: Multicenter, cross-sectional survey of family members of patients admitted to ICUs at the University of Maryland Medical Center, Johns Hopkins University Hospital, and Christiana Hospital. Family members of ICU patients were evaluated using the Epworth Sleepiness Scale, a validated survey assessing sleepiness in everyday situations (normal, less than 10); the Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10), a questionnaire quantifying the impact of sleepiness on daily activities (normal, at least 17.9); and psychomotor vigilance testing, a test of cognitive function, in relation to sleep deprivation (normal mean reaction time less than 500 ms). RESULTS: A total of 225 family members were assessed. Of these, 50.2 % (113/225) had Epworth scores consistent with excessive daytime sleepiness. Those with sleepiness experienced greater impairment in performing daily activities by FOSQ-10 (15.6 ± 3.0 vs 17.4 ± 2.2, p < 0.001). Cognitive blunting was found in 13.3 % (30/225) of family members and 15.1 % (14/93) of surrogate decision-makers. Similar rates of cognitive blunting as reported by mean reaction time of at least 500 ms were found among family members whether or not they reported sleepiness (15.0 % (17/113) vs. 11.6 % (13/112), p = 0.45). CONCLUSIONS: Half of the family members of ICU patients suffer from excessive daytime sleepiness. This sleepiness is associated with functional impairment, but not cognitive blunting.


Subject(s)
Critical Illness , Family , Sleep Stages , Cross-Sectional Studies , Data Collection , Female , Humans , Intensive Care Units , Male , Middle Aged
8.
PLoS Genet ; 9(9): e1003605, 2013.
Article in English | MEDLINE | ID: mdl-24039590

ABSTRACT

A robust, bistable switch regulates the fluctuations between wakefulness and natural sleep as well as those between wakefulness and anesthetic-induced unresponsiveness. We previously provided experimental evidence for the existence of a behavioral barrier to transitions between these states of arousal, which we call neural inertia. Here we show that neural inertia is controlled by processes that contribute to sleep homeostasis and requires four genes involved in electrical excitability: Sh, sss, na and unc79. Although loss of function mutations in these genes can increase or decrease sensitivity to anesthesia induction, surprisingly, they all collapse neural inertia. These effects are genetically selective: neural inertia is not perturbed by loss-of-function mutations in all genes required for the sleep/wake cycle. These effects are also anatomically selective: sss acts in different neurons to influence arousal-promoting and arousal-suppressing processes underlying neural inertia. Supporting the idea that anesthesia and sleep share some, but not all, genetic and anatomical arousal-regulating pathways, we demonstrate that increasing homeostatic sleep drive widens the neural inertial barrier. We propose that processes selectively contributing to sleep homeostasis and neural inertia may be impaired in pathophysiological conditions such as coma and persistent vegetative states.


Subject(s)
Drosophila Proteins/genetics , Ion Channels/genetics , Membrane Proteins/genetics , Shaker Superfamily of Potassium Channels/genetics , Wakefulness/genetics , Animals , Arousal/genetics , Arousal/physiology , Brain/metabolism , Brain/physiology , Circadian Rhythm/physiology , Drosophila melanogaster/genetics , Drosophila melanogaster/physiology , Homeostasis/physiology , Humans , Mutation , Neurons/metabolism , Sleep/genetics
9.
Anesthesiology ; 115(4): 702-12, 2011 Oct.
Article in English | MEDLINE | ID: mdl-21934405

ABSTRACT

BACKGROUND: General anesthesia has been likened to a state in which anesthetized subjects are locked out of access to both rapid eye movement (REM) sleep and wakefulness. Were this true for all anesthetics, a significant REM rebound after anesthetic exposure might be expected. However, for the intravenous anesthetic propofol, studies demonstrate that no sleep debt accrues. Moreover, preexisting sleep debts dissipate during propofol anesthesia. To determine whether these effects are specific to propofol or are typical of volatile anesthetics, the authors tested the hypothesis that REM sleep debt would accrue in rodents anesthetized with volatile anesthetics. METHODS: Electroencephalographic and electromyographic electrodes were implanted in 10 mice. After 9-11 days of recovery and habituation to a 12 h:12 h light-dark cycle, baseline states of wakefulness, nonrapid eye movement sleep, and REM sleep were recorded in mice exposed to 6 h of an oxygen control and on separate days to 6 h of isoflurane, sevoflurane, or halothane in oxygen. All exposures were conducted at the onset of light. RESULTS: Mice in all three anesthetized groups exhibited a significant doubling of REM sleep during the first 6 h of the dark phase of the circadian schedule, whereas only mice exposed to halothane displayed a significant increase in nonrapid eye movement sleep that peaked at 152% of baseline. CONCLUSION: REM sleep rebound after exposure to volatile anesthetics suggests that these volatile anesthetics do not fully substitute for natural sleep. This result contrasts with the published actions of propofol for which no REM sleep rebound occurred.


Subject(s)
Anesthetics, Inhalation/pharmacology , Sleep Deprivation/chemically induced , Sleep, REM/drug effects , Anesthesia, Inhalation , Anesthetics, Intravenous/pharmacology , Animals , Electrodes, Implanted , Electroencephalography/drug effects , Electromyography/drug effects , Halothane/pharmacology , Isoflurane/pharmacology , Male , Methyl Ethers/pharmacology , Mice , Mice, Inbred C57BL , Polysomnography/drug effects , Propofol/pharmacology , Sevoflurane , Sleep/drug effects , Sleep Deprivation/physiopathology
10.
Cancer Invest ; 29(4): 266-71, 2011 May.
Article in English | MEDLINE | ID: mdl-21345074

ABSTRACT

How do oncologists choose therapy for the elderly? Oncologists assigned patients aged 65 years or older with incurable non-small cell lung cancer to: (a) carboplatin (AUC = 2) + paclitaxel 50 mg/m(2) days 1, 8, 15 (28-day cycle × 4) followed by gefitinib; or (b) gefitinib 250 mg/day. With (a), 12 of 34 were progression-free at 6 months; median time to cancer progression was 3.9 months. With (b), the same occurred in 11 of 28 patients with the latter being 4.9 months. The most common reason for conventional chemotherapy was oncologists' opinion that the cancer was aggressive, and for gefitinib alone, patients' reluctance to receive chemotherapy. Interestingly, age had no influence.


Subject(s)
Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Carcinoma, Non-Small-Cell Lung/drug therapy , Lung Neoplasms/drug therapy , Practice Patterns, Physicians' , Age Factors , Aged , Aged, 80 and over , Antineoplastic Combined Chemotherapy Protocols/adverse effects , Carboplatin/administration & dosage , Carcinoma, Non-Small-Cell Lung/mortality , Disease-Free Survival , Female , Gefitinib , Humans , Lung Neoplasms/mortality , Male , Paclitaxel/administration & dosage , Patient Selection , Practice Patterns, Physicians'/statistics & numerical data , Quinazolines/administration & dosage , Surveys and Questionnaires , Survival Analysis , Time Factors , Treatment Outcome , United States
11.
PLoS One ; 5(7): e11903, 2010 Jul 30.
Article in English | MEDLINE | ID: mdl-20689589

ABSTRACT

One major unanswered question in neuroscience is how the brain transitions between conscious and unconscious states. General anesthetics offer a controllable means to study these transitions. Induction of anesthesia is commonly attributed to drug-induced global modulation of neuronal function, while emergence from anesthesia has been thought to occur passively, paralleling elimination of the anesthetic from its sites in the central nervous system (CNS). If this were true, then CNS anesthetic concentrations on induction and emergence would be indistinguishable. By generating anesthetic dose-response data in both insects and mammals, we demonstrate that the forward and reverse paths through which anesthetic-induced unconsciousness arises and dissipates are not identical. Instead they exhibit hysteresis that is not fully explained by pharmacokinetics as previously thought. Single gene mutations that affect sleep-wake states are shown to collapse or widen anesthetic hysteresis without obvious confounding effects on volatile anesthetic uptake, distribution, or metabolism. We propose a fundamental and biologically conserved concept of neural inertia, a tendency of the CNS to resist behavioral state transitions between conscious and unconscious states. We demonstrate that such a barrier separates wakeful and anesthetized states for multiple anesthetics in both flies and mice, and argue that it contributes to the hysteresis observed when the brain transitions between conscious and unconscious states.


Subject(s)
Anesthetics/therapeutic use , Brain/drug effects , Brain/physiology , Unconsciousness/chemically induced , Wakefulness/drug effects , Animals , Central Nervous System/drug effects , Drosophila , Male , Mice , Mice, Inbred C57BL
14.
Respir Physiol Neurobiol ; 134(1): 33-41, 2003 Feb 19.
Article in English | MEDLINE | ID: mdl-12573879

ABSTRACT

Serum (IS) was obtained 0.5, 2, 4 or 6 h after inoculating s.c. six rabbits (approximately 2 kg) in each time period with 1 mg/kg of Tityus discrepans (Td) venom; the control was serum obtained from four rabbits 4 h after injecting them 1 ml s.c. of 0.9% NaCl. IS produced a transient (<25 min) rise in pulmonary artery pressure of isolated and perfused rabbit lungs, other lung parameters were not altered. We found that both scorpion venom and IS produced a approximately 50% transient increase of transendothelial electric resistance in cultured tissue human umbilical cord vein. Neither venom nor IS changed the transepithelial electrical resistance of tissue cultured human airway epithelia. The experiments suggest that humoral factors contained in the inoculated serum modify vascular endothelium in a much more effective manner than the venom by itself. These experiments also make it unlikely that vascular endothelium is the source of the humoral factors contained in inflammatory serum.


Subject(s)
Pulmonary Circulation/drug effects , Respiratory Mucosa/drug effects , Scorpion Venoms/pharmacology , Animals , Cells, Cultured , Humans , In Vitro Techniques , Lung/blood supply , Lung/drug effects , Lung/physiology , Pulmonary Artery/drug effects , Pulmonary Artery/physiology , Pulmonary Circulation/physiology , Rabbits , Respiratory Mucosa/cytology , Respiratory Mucosa/physiology
15.
Clín. méd. H.C.C ; 2(3): 188-91, sept.-dic. 1997.
Article in Spanish | LILACS | ID: lil-275692

ABSTRACT

La enfermedad vascular pulmonar (EVP) que ocurre en nuestros pacientes con enfermedad broncopulmonar obstructiva crónica (EBPOC) es una complicación común y seria. Se ha estimado que el 50 por ciento de los pacientes mayores de los 50 años y que poseen una EBPOC presentan hipertensión pulmonar y, por ende EVP. La tasa de sobrevida de estos pacientes se asemeja bastante a la tasa que presentan los pacientes con cáncer de pulmón inoperable. Esta enfermedad (EVP) disminuye aún más la captación de O² por el pulmón. También produce una disminución de la calidad de vida del paciente² y como los síntomas que produce la EVPson silentes o se asemejan mucho a los que produce la EBPOC es común que el médico no se percate de que está ocurriendo. En este artículo discutimos la clínica, la fisiopatología y los nuevos métodos de tratamiento de esta complicación que con frecuencia acompaña a la enfermedad pulmonar


Subject(s)
Humans , Animals , Female , Lung Diseases, Obstructive/complications , Lung Diseases, Obstructive/diagnosis , Lung Diseases, Obstructive/physiopathology , Vascular Diseases/diagnosis , Vascular Diseases/physiopathology , Vascular Diseases/therapy
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