The involvement of physician assistants in inpatient care in hospitals in the Netherlands: a cost-effectiveness analysis.

OBJECTIVE: To investigate the cost-effectiveness of substitution of inpatient care from medical doctors (MDs) to physician assistants (PAs). DESIGN: Cost-effectiveness analysis embedded within a multicentre, matched-controlled study. The traditional model in which only MDs are employed for inpatient care (MD model) was compared with a mixed model in which, besides MDs, PAs are also employed (PA/MD model). SETTING: 34 hospital wards across the Netherlands. PARTICIPANTS: 2292 patients were followed from admission until 1 month after discharge. Patients receiving daycare, terminally ill patients and children were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES: All direct healthcare costs from day of admission until 1 month after discharge. Health outcome concerned quality-adjusted life years (QALYs), which was measured with the EuroQol five dimensions questionnaire (EQ-5D). RESULTS: We found no significant difference for QALY gain (+0.02, 95% CI -0.01 to 0.05) when comparing the PA/MD model with the MD model. Total costs per patient did not significantly differ between the groups (+€568, 95% CI -€254 to €1391, p=0.175). Regarding the costs per item, a difference of €309 per patient (95% CI €29 to €588, p=0.030) was found in favour of the MD model regarding length of stay. Personnel costs per patient for the provider who is primarily responsible for medical care on the ward were lower on the wards in the PA/MD model (-€11, 95% CI -€16 to -€6, p<0.01). CONCLUSIONS: This study suggests that the cost-effectiveness on wards managed by PAs, in collaboration with MDs, is similar to the care on wards with traditional house staffing. The involvement of PAs may reduce personnel costs, but not overall healthcare costs. TRIAL REGISTRATION NUMBER: NCT01835444.

Health care utilization one year following the diagnosis benign breast disease or breast cancer.

PURPOSE: We analyzed health care utilization (HCU) and its predictors in the first year after the diagnostic process for breast cancer (BC) or benign breast disease (BBD) using questionnaires. The impact of trait anxiety on HCU was examined. RESULTS: In total 591 women were analyzed, 440 with BBD and 151 with BC. In women with BBD and high trait anxiety (HTA) increased HCU was found. In women with BC and HTA only more use of psychosocial care (PS) was found. HCU in BBD was predicted by lower Quality of Life (QoL) and (adjuvant) treatment predicted HCU in BC. CONCLUSIONS: The most important factors for higher HCU were HTA and lower QoL, especially in BBD. In women with BC increased PS use was seen in chronically anxious women. Therefore, it is important to identify these women using a psychometric test and to anticipate to their specific (mental) health care needs.

The impact of postmastectomy radiotherapy on local control in patients with invasive lobular breast cancer.

PURPOSE: The aim of this population-based study was to examine the impact of postmastectomy radiotherapy on the risk of local recurrence in patients with invasive lobular breast cancer (ILC). METHODS: The population-based Eindhoven Cancer Registry was used to select all patients with ILC, who underwent mastectomy in five general hospitals in the southern part of the Netherlands between 1995 and 2002. Of the 499 patients 383 patients fulfilled the eligibility criteria. Of these patients, 170 (44.4%) had received postmastectomy radiotherapy. The median follow-up was 7.2 years. Fourteen patients (3.7%) were lost to follow-up. RESULTS: During follow-up 22 patients developed a local recurrence, of whom 4 had received postmastectomy radiotherapy. The 5-year actuarial risk of local recurrence was 2.1% for the patients with and 8.7% for the patients without postmastectomy radiotherapy. After adjustment for age at diagnosis, tumour stage and adjuvant systemic treatment, the patients who underwent postmastectomy radiotherapy were found to have a more than 3 times lower risk of local recurrence compared to the patients without (Hazard Ratio 0.30; 95% Confidence Interval: 0.10-0.89). CONCLUSION: Local control is excellent for patients with ILC who undergo postmastectomy radiotherapy and significantly better than for patients not receiving radiotherapy.

Risk factors for non-sentinel lymph node metastases in patients with breast cancer. The outcome of a multi-institutional study.

BACKGROUND: In this multi-institutional prospective study, we evaluated whether we could identify risk factors predictive for non-sentinel lymph node (non-SN) metastases in breast cancer patients with a positive sentinel lymph node (SN). METHODS: In this multi-institutional study, 541 eligible breast cancer patients were included prospectively. RESULTS: The occurrence of non-SN metastases was related to the size of the SN metastasis (P = .02), primary tumor size (P = .001), and lymphovascular invasion (P = .07). The adjusted odds ratio was 3.1 for SN micro-metastasis compared with SN isolated tumor cells, 4.0 for SN macro-metastasis versus SN isolated tumor cells, 3.1 for tumor size (>3.0 cm compared with 3.0 cm, and with vessel invasion. CONCLUSION: We identified three predictive factors for non-SN metastases in breast cancer patients with a positive SN: size of the SN metastasis; primary tumor size; and vessel invasion. We were not able to identify a specific group of patients with a positive SN in whom the risk for non-SN metastases was less than 5%.

Differences in sentinel lymph node pathology protocols lead to differences in surgical strategy in breast cancer patients.

BACKGROUND: Internationally, there is no consensus on the pathology protocol to be used to examine the sentinel lymph node (SN). At present, therefore, various hospitals use different SN pathology protocols of which the effect has not been fully elucidated. We hypothesized that differences between hospitals in SN pathology protocols affect subsequent surgical treatment strategies. METHODS: Patients from four hospitals (A-D) were prospectively registered when they underwent an SN biopsy. In hospitals A, B, and C, three levels of the SN were examined pathologically, whereas in hospital D, at least seven additional levels were examined. In the absence of apparent metastases with hematoxylin and eosin examination, immunohistochemical examination was performed in all four hospitals. RESULTS: In total, 541 eligible patients were included. In hospital D, more patients were diagnosed with a positive SN (P < .001) as compared with hospitals A, B, and C, mainly because of increased detection of isolated tumor cells. This led to more completion axillary lymph node dissections in hospital D (66.3% of patients (P < .0001), compared with 29.0% in hospitals A, B, and C combined). Positive non-SNs were detected in 13.9% of patients in hospital D, compared with 9.7% in hospitals A, B, and C (P = .70). That is, in 52.4% of patients in hospital D, a negative completion axillary lymph node dissection was performed, compared with 19.3% of patients in hospitals A, B, and C combined. CONCLUSIONS: Differences in SN pathology protocols between hospitals do have a substantial effect on SN findings and subsequent surgical treatment strategies. Whether ultrastaging and, thus, additional surgery can offer better survival remains to be determined.

Pulmonary glutamine production: effects of sepsis and pulmonary infiltrates.

OBJECTIVE: To define the role of the lung in the production of glutamine in the critically ill and to determine the effects of the presence of pulmonary infiltrates and the presence and severity of sepsis. DESIGN AND SETTING: Prospective clinical study in a single center; interdisciplinary intensive care unit at a university hospital. PATIENTS: Eleven critically ill patients were compared to ten patients prior to cardiac bypass surgery. MEASUREMENTS AND RESULTS: Fluxes of glutamine and other amino acids were measured. Chest radiography was performed, and APACHE II and multiple-organ failure scores were calculated. Septic patients showed significantly higher glutamine efflux from the lungs than controls. At least one-half of this glutamine is estimated to result from protein breakdown. Severity of illness had no impact on glutamine fluxes. In the presence of pulmonary infiltrates on chest radiographs glutamine efflux did not differ from zero. CONCLUSIONS: The lungs produce significant amounts of glutamine in septic patients. Pulmonary infiltrates decrease the glutamine efflux from the lung in septic patients. We suggest that this is caused by uptake of glutamine by white cells in the lung exerting immunological functions.