A detailed report of the resource use and costs associated with implementation of a short stay programme for breast cancer surgery.

BACKGROUND: Despite the increased attention for assessing the effectiveness of implementation strategies, most implementation studies provide little or no information on its associated costs. The focus of the current study was to provide a detailed report of the resource use and costs associated with implementation of a short stay programme for breast cancer surgery in four Dutch hospitals. METHODS: The analysis was performed alongside a multi-centre implementation study. The process of identification, measurement and valuation of the implementation activities was based on recommendations for the design, analysis and reporting of health technology assessments. A scoring form was developed to prospectively determine the implementation activities at professional and implementation expert level. A time horizon of 5 years was used to calculate the implementation costs per patient. RESULTS: Identified activities were consisted of development and execution of the implementation strategy during the implementation project. Total implementation costs over the four hospitals were €83.293. Mean implementation costs, calculated for 660 patients treated over a period of 5 years, were €25 per patient. Subgroup analyses showed that the implementation costs ranged from €3.942 to €32.000 on hospital level. From a local hospital perspective, overall implementation costs were €21 per patient, after exclusion of the costs made by the expert centre. CONCLUSIONS: We provided a detailed case description of how implementation costs can be determined. Notable differences in implementation costs between hospitals were observed. ISRCTN: ISRCTN77253391.

Cost-effectiveness of a short stay admission programme for breast cancer surgery.

BACKGROUND: Short stay (admission, surgery, and discharge the same day or within 24 hours) following breast cancer surgery is part of an established care protocol but as yet not well implemented in Europe. Alongside a before-after multi-centre implementation study, an economic evaluation was performed exploring the cost-effectiveness of a short stay programme (SSP) versus care as usual (CAU). MATERIAL AND METHODS: In the implementation study, 324 patients were included. In the economic evaluation a societal perspective was applied with a six week time horizon. Cost data were obtained from Case Record Forms and cost diaries. Effectiveness was assessed by calculating Quality Adjusted Life Years (QALYs), using the EuroQol-5D. Cost-effectiveness was expressed as the incremental costs per QALY. RESULTS: Mean societal costs decreased by euro955,- (95% CI euro - 2104,- to euro157,-) for patients in SSP (n=127) compared with CAU (n=135). Mean healthcare costs differed euro883,- (95% CI euro - 1560,- to euro870,-) in favour of SSP. The incremental cost-effectiveness ratio could not be calculated due to similar effectiveness for both groups, i.e. the difference in QALYs was zero. The cost-effectiveness acceptability curves showed that the probability that SSP was more cost-effective than CAU was over 90% in the base-case analysis. DISCUSSION: A short stay programme as implemented is cost-effective compared with care as usual. In achieving good and more efficient quality of care, larger scale implementation is warranted.

Investigating the complementary value of discrete choice experiments for the evaluation of barriers and facilitators in implementation research: a questionnaire survey.

BACKGROUND: The potential barriers and facilitators to change should guide the choice of implementation strategy. Implementation researchers believe that existing methods for the evaluation of potential barriers and facilitators are not satisfactory. Discrete choice experiments (DCE) are relatively new in the health care sector to investigate preferences, and may be of value in the field of implementation research. The objective of our study was to investigate the complementary value of DCE for the evaluation of barriers and facilitators in implementation research. METHODS: Clinical subject was the implementation of the guideline for breast cancer surgery in day care. We identified 17 potential barriers and facilitators to the implementation of this guideline. We used a traditional questionnaire that was made up of statements about the potential barriers and facilitators. Respondents answered 17 statements on a five-point scale ranging from one (fully disagree) to five (fully agree). The potential barriers and facilitators were included in the DCE as decision attributes. Data were gathered among anaesthesiologists, surgical oncologists, and breast care nurses by means of a paper-and-pencil questionnaire. RESULTS: The overall response was 10%. The most striking finding was that the responses to the traditional questionnaire hardly differentiated between barriers. Forty-seven percent of the respondents thought that DCE is an inappropriate method. These respondents considered DCE too difficult and too time-consuming. Unlike the traditional questionnaire, the results of a DCE provide implementation researchers and clinicians with a relative attribute importance ranking that can be used to prioritize potential barriers and facilitators to change, and hence to better fine-tune the implementation strategies to the specific problems and challenges of a particular implementation process. CONCLUSION: The results of our DCE and traditional questionnaire would probably lead to different implementation strategies. Although there is no 'gold standard' for prioritising potential barriers and facilitators to the implementation of change, theoretically, DCE would be the method of choice. However, the feasibility of using DCE was less favourable. Further empirical applications should investigate whether DCE can really make a valuable contribution to the implementation science.

Implementation of an ultra-short-stay program after breast cancer surgery in four hospitals: perceived barriers and facilitators.

BACKGROUND: The objective of this study was to identify barriers and facilitators that professionals see when implementing a program incorporating ultra-short hospital admission in the treatment of breast cancer. Such an intervention is an essential step when designing a strategy for implementation of a care program that is different from established daily routines. METHODS: In a prospective quasi-experimental study qualitative data were collected from four hospitals in the Netherlands between January 2005 and July 2006. Potential barriers and facilitators for successful implementation were extracted from detailed notes of all contacts between the researchers and each participating hospital. Subsequently, these items were categorized according to themes. RESULTS: Over 40 items were identified. Most barriers concerned organizational and program-related aspects, whereas the most common facilitators addressed organizational issues. Six of the 29 study recommendations were perceived as impeding or facilitating. Thirty of the 40 barriers were mentioned in one hospital only. Several key factors were found that determine the success of implementation of an ultrashort-stay program. Provision of care in the home setting should be assured. Policy makers and insurance companies should acknowledge that multidisciplinary care teams and teams integrating primary and secondary care fulfill important roles in delivering continuity of care. Specific strategies should be set out to convince everybody in the organization about the new ideas, particularly the minority of people who do not agree with the plans. CONCLUSIONS: A set of barriers and facilitators for implementation of the program was described that may be used by any professional preparing to perform breast cancer surgery in an ultrashort-stay facility. The systematic approach that led to this set may be used by any healthcare professional concerned with implementation and consolidation of innovative programs in healthcare in order to enhance the effectiveness of the chosen strategy.

Introduction of a breast cancer care programme including ultra short hospital stay in 4 early adopter centres: framework for an implementation study.

BACKGROUND: Whereas ultra-short stay (day care or 24 hour hospitalisation) following breast cancer surgery was introduced in the US and Canada in the 1990s, it is not yet common practice in Europe. This paper describes the design of the MaDO study, which involves the implementation of ultra short stay admission for patients after breast cancer surgery, and evaluates whether the targets of the implementation strategy are reached. The ultra short stay programme and the applied implementation strategy will be evaluated from the economic perspective. METHODS/DESIGN: The MaDO study is a pre-post-controlled multi-centre study, that is performed in four hospitals in the Netherlands. It includes a pre and post measuring period of six months each with six months of implementation in between in at least 40 patients per hospital per measurement period. Primary outcome measure is the percentage of patients treated in ultra short stay. Secondary endpoints are the percentage of patients treated according to protocol, degree of involvement of home care nursing, quality of care from the patient's perspective, cost-effectiveness of the ultra short stay programme and cost-effectiveness of the implementation strategy. Quality of care will be measured by the QUOTE-breast cancer instrument, cost-effectiveness of the ultra short stay programme will be measured by means of the EuroQol (administered at four time-points) and a cost book for patients. Cost-effectiveness analysis will be performed from a societal perspective. Cost-effectiveness of the implementation strategy will be measured by determination of the costs of implementation activities. DISCUSSION: This study will reveal barriers and facilitators for implementation of the ultra short stay programme. Moreover, the results of the study will provide information about the cost-effectiveness of the ultra short stay programme and the implementation strategy. TRIAL REGISTRATION: Current Controlled Trials ISRCTN77253391.

The patient's perspective of the quality of breast cancer care. The development of an instrument to measure quality of care through focus groups and concept mapping with breast cancer patients.

Quality of care is often described by professionals. However, in this study breast cancer patients participated in developing an instrument that reflects quality of care from the patient's perspective. Through focus groups and concept mapping patients' ideas on determinants of good quality of care were generated and categorised according to similarity and importance. Information from eight focus group interviews with a total of 72 participants yielded 221 quality of care aspects. Following reduction, 81 aspects were used for categorisation during six concept mapping sessions with 67 participants. After analysis, 55 aspects remained grouped into six clusters. This study was conducted with a large number of breast cancer patients, undergoing the full range of treatment modalities, in different hospitals, in different areas in the Netherlands. Therefore, this set of quality of care indicators can be considered valid and suitable for the evaluation of breast cancer care as experienced by patients.

Bronchial muscle peristaltic activity in the fetal rat.

Aside for the potential for tonic contraction, the airway smooth muscle exhibits intermittent phasic rhythmic activity that may contribute to lung growth during fetal life. Therefore, we examined 4th generation rat 18-22 d gestation fetal, 4-6 d of age newborn and adult bronchial ring from Sprague Dawley rats to compare differences in smooth muscle function. We hypothesized that phasic contractions were greatest before birth. Bronchial muscle spontaneous rhythmic contractions were greatest in the fetus and absent in the adult. In response to KCl stimulation, the fetal bronchial smooth muscle only developed tonic force that was 3.5 +/- 0.6 and lower than measured in the newborn 9.0 +/- 0.3 and adult 13.7 +/- 1.4 mN/mm2. The thromboxane A2 analogue U46619 induced tonic and phasic muscle contractions and the amplitude and frequency of the phasic contractions were greater in the fetus as compared with the adult and increased with gestational age. The U46619-induced rhythmic contractions were abrogated by ryanodine, thapsigargin and reduction of extracellular Na+, suggesting intracellular Ca2+ dependence and involvement of the Na+/Ca2+ exchanger. The inward rectifier K+ blocker BaCl2 induced phasic contractions in unstimulated fetal, but not adult bronchial muscle of the same amplitude and frequency as for the spontaneous and U46619-induced ones. We conclude that the airway smooth muscle phasic activity is greatest in the fetus and tends to disappear post-natally with age suggesting an in utero role during lung development.