Characterization of time toxicity in older patients with metastatic breast cancer.

PURPOSE: Recognizing that receiving healthcare can be time intensive and burdensome, time toxicity has been conceptualized as the time spent by patients seeking healthcare. This study investigates the association between age at diagnosis and time toxicity for patients with Metastatic Breast Cancer (MBC) and identifies major components of care that confer the greatest time toxicity. METHODS: We conducted a retrospective cohort study among patients with MBC aged 67 or older using the SEER-Medicare database. We assessed time toxicity using the number of encounter days patients interacted with the healthcare system per 100 days, within the first year of starting cancer treatment. We used a Poisson model to analyze the association between age and encounter days, adjusting for clinical and sociodemographic factors. We stratified the mean encounter days for each age cohort by treatment types. FINDINGS: The final sample included 2949 patients; 51.4% were between 70 and 79 years old, and 81.3% were white. Although unadjusted analysis showed an association between older age and more encounter days (Rate Ratio (RR) 1.12; 95% CI 1.02, 1.22), there was no significant association after adjusting for comorbidities and treatment type. Patients with more than three comorbidities had significantly higher encounter days compared to those without comorbidities [RR 1.36 (95% CI 1.26, 1.46)]. Receipt of radiotherapy [RR: 1.45 95% CI (1.37, 1.54)] was associated with more encounter days compared to not receiving radiotherapy, while receipt of bone-modifying agents was associated with fewer encounter days compared to not using Bone modifying agents [RR 0.75 (95% CI 0.70, 0.79)]. CONCLUSION: Our study identified comorbidities and cancer treatment modality, including radiotherapy, as the factors affecting time toxicity in older patients with MBC. Assessment of an individual's comorbid medical conditions and types of treatment planned are crucial to understanding age-related impacts on encounter days and to support shared decision making in older patients.

Time Cost and Demand: Implications for Public Policy.

The success of policy involves not only good design but a good understanding of how the public will respond behaviorally to the benefits or detriments of that policy. Behavioral science has greatly contributed to how we understand the impact of monetary costs on behavior and has therefore contributed to policy design. Consumption taxes are a direct result of this; for example, cigarette taxes that aim to reduce cigarette consumption. In addition to monetary costs, time may also be conceptualized as a constraint on consumption. Time costs may therefore have policy implications, for example, long waiting times could deter people from accessing certain benefits. Recent data show that behavioral economic demand curve methods used to understand monetary cost may also be used to understand time costs. In this article we discuss how the impact of time cost can be conceptualized as a constraint on demand for public benefits utilization and public health when there are delays to receiving the benefits. Policy examples in which time costs may be relevant and demand curve methods may be useful are discussed in the areas of government benefits, public health, and transportation design.

Economic Impact of the Implementation of an Enhanced Recovery after Surgery (ERAS) Protocol in a Bariatric Patient Undergoing a Roux-En-Y Gastric Bypass.

INTRODUCTION: Enhanced Recovery After Surgery (ERAS) protocols have proven to be cost-effective in various surgical procedures, mainly in colorectal surgeries. However, there is still little scientific evidence evaluating the economic impact of their application in bariatric surgery. The present study aimed to compare the economic cost of performing a laparoscopic Roux-en-Y gastric bypass following an ERAS protocol, with the costs of following a standard-of-care protocol. PATIENTS AND METHODS: A prospective non-randomized study of patients undergoing Roux-en-Y gastric bypass was performed. Patients were divided into two groups: patients following an ERAS protocol and patients following a standard-of-care protocol. The total costs of the procedure were subdivided into pharmacological expenditures, surgical material, and time expenses, the price of complementary tests performed during the hospital stay, and costs related to the hospital stay. RESULTS: The 84 patients included 58 women (69%) and 26 men (31%) with a mean age of 44.3 ± 11.6 years. There were no significant differences in age, gender, and distribution of comorbidities between groups. Postoperative pain, nausea or vomiting, and hospital stay were significantly lower within the ERAS group. The pharmacological expenditures, the price of complementary tests performed during the hospital stay, and the costs related to the hospital stay, were significantly lower in the ERAS group. There were no significant differences in the surgical material and surgical time costs between groups. Globally, the total cost of the procedure was significantly lower in the ERAS group with a mean saving of 1458.62$ per patient. The implementation of an ERAS protocol implied a mean saving of 21.25% of the total cost of the procedure. CONCLUSIONS: The implementation of an ERAS protocol significantly reduces the perioperative cost of Roux-en-Y gastric bypass.

Estimation of time cost of anti-cancer drugs approved based on comparisons to best supportive care: A cross sectional analysis.

BACKGROUND: Financial costs from cancer treatment are increasingly recognized, but what has historically been underrecognized is the time cost of therapy. We sought to estimate the time burden of anti-cancer drugs approved based on comparisons to best supportive care (BSC), with the assumption that without this drug, a patient could have been treated with observation, home palliative care or hospice services, with minimal time seeking medical care. METHODS: We searched all FDA approvals (2009 - March 2022) for randomized trials that used BSC as a treatment option for an anti-tumor drug in the metastatic setting and abstracted data on treatment related activities. We then estimated time spent on these activities using previously calculated times. RESULTS: Of the 13 drugs tested against BSC, nine studies demonstrated an improvement in median OS (median 2.1 months). The median monthly time spent for patients in the intervention arm of BSC trials was 15.8 h. CONCLUSION: Time is a valuable resource for people who have cancer, but especially for patients who may have few to no remaining treatment options, and yet, we found that patients can spend up to 16 h in anti-cancer drug related activities per month. POLICY SUMMARY: Because survival outcomes are variable for patients being treated in later lines of therapy, time resources are a valuable consideration in the treatment plan.

An equity analysis on the household costs of accessing and utilising maternal and child health care services in Tanzania.

BACKGROUND: Direct and time costs of accessing and using health care may limit health care access, affect welfare loss, and lead to catastrophic spending especially among poorest households. To date, limited attention has been given to time and transport costs and how these costs are distributed across patients, facility and service types especially in poor settings. We aimed to fill this knowledge gap. METHODS: We used data from 1407 patients in 150 facilities in Tanzania. Data were collected in January 2012 through patient exit-interviews. All costs were disaggregated across patients, facility and service types. Data were analysed descriptively by using means, medians and equity measures like equity gap, ratio and concentration index. RESULTS: 71% of patients, especially the poorest and rural patients, accessed care on foot. The average travel time and cost were 30 minutes and 0.41USD respectively. The average waiting time and consultation time were 47 min and 13 min respectively. The average medical cost was 0.23 USD but only18% of patients paid for health care. The poorest and rural patients faced substantial time burden to access health care (travel and waiting) but incurred less transport and medical costs compared to their counterparts. The consultation time was similar across patients. Patients spent more time travelling to public facilities and dispensaries while incurring less transport cost than accessing other facility types, but waiting and consultation time was similar across facility types. Patients paid less amount in public than in private facilities. Postnatal care and vaccination clients spent less waiting and consultation time and paid less medical cost than antenatal care clients. CONCLUSIONS: Our findings reinforce the need for a greater investment in primary health care to reduce access barriers and cost burdens especially among the worse-offs. Facility's construction and renovation and increased supply of healthcare workers and medical commodities are potential initiatives to consider. Other initiatives may need a multi-sectoral collaboration.

The Economic Burden of Cancer in Canada from a Societal Perspective.

Cancer patients and their families experience considerable financial hardship; however, the current published literature on the economic burden of cancer at the population level has typically focused on the costs from the health system's perspective. This study aims to estimate the economic burden of cancer in Canada from a societal perspective. The analysis was conducted using the OncoSim-All Cancers model, a Canadian cancer microsimulation model. OncoSim simulates cancer incidence and deaths using incidence and mortality data from the Canadian Cancer Registry and demography projections from Statistics Canada. Using a phase-based costing framework, we estimated the economic burden of cancer in Canada in 2021 by incorporating published direct health system costs and patients' and families' costs (out-of-pocket costs, time costs, indirect costs). From a societal perspective, cancer-related costs were CAD 26.2 billion in Canada in 2021; 30% of costs were borne by patients and their families. The economic burden was the highest in the first year after cancer was diagnosed (i.e., initial care). During this time, patients and families' costs amounted to almost CAD 4.8 billion in 2021. This study provides a comprehensive estimate of the economic burden of cancer, which could inform cost-benefit analyses of proposed cancer prevention interventions.

Time Costs and Out-of-Pocket Costs in Patients With Chronic Hepatitis C in a Publicly Funded Health System.

OBJECTIVES: Chronic hepatitis C (CHC) infection affects more than 70 million people worldwide and imposes considerable health and economic burdens on patients and society. This study estimated 2 understudied components of the economic burden, patient out-of-pocket (OOP) costs and time costs, in patients with CHC in a tertiary hospital clinic setting and a community clinic setting. METHODS: This was a multicenter, cross-sectional study with hospital-based (n = 174) and community-based (n = 101) cohorts. We used a standardized instrument to collect healthcare resource use, time, and OOP costs. OOP costs included patient-borne costs for medical services, nonprescription drugs, and nonmedical expenses related to healthcare visits. Patient and caregiver time costs were estimated using an hourly wage value derived from patient-reported employment income and, where missing, derived from the Canadian census. Sensitivity analysis explored alternative methods of valuing time. Costs were reported in 2020 Canadian dollars. RESULTS: The mean 3-month OOP cost was $55 (95% confidence interval [CI] $21-$89) and $299 (95% CI $170-$427) for the community and hospital cohorts, respectively. The mean 3-month patient time cost was $743 (95% CI $485-$1002) (community) and $465 (95% CI $248-$682) (hospital). The mean 3-month caregiver time cost was $31 (95% CI $0-$63) (community) and $277 (95% CI $174-$380) (hospital). Patients with decompensated cirrhosis bore the highest costs. CONCLUSIONS: OOP costs and patient and caregiver time costs represent a considerable economic burden to patient with CHC, equivalent to 14% and 21% of the reported total 3-month income for the hospital-based and community-based cohorts, respectively.

Parenting-allocated time in families of the Ural Russian region: amounts and determinants / Tempo alocado para a paternidade em famílias da região Ural da Rússia: quantidades e determinantes / Tiempo asignado a la crianza en familias de la región Ural de Rusia: cantidades y determinantes

Abstract This study aims to measure the time allocated to child raising using parents' self-assessment and the criterion of subjective time sufficiency or insufficiency. We surveyed 545 Russian parents from the Ural region and used factor analysis to identify the main determinants that affect the self-assessment of time allocated to parenting. We found that parents in the Russian Ural region believe they do not spend enough time with their children. Reasons for the insufficient amount of time allocated to parenting are the following: overload of labor duties at home and at work, psychological causes of intergenerational interaction, external reasons − studies, poor health, the need to care for other relatives and so on.

Resumo Este estudo tenta medir o tempo alocado aos filhos por meio da autoavaliação dos pais e do critério de suficiência subjetiva ou tempo insuficiente. Foram pesquisados 545 pais russos da região dos Urais e utilizou-se a análise fatorial para identificar os principais determinantes que afetam a autoavaliação do tempo alocado pelos pais. Verificou-se que os pais nas regiões russas dos Urais têm uma opinião comum de que não passam tempo suficiente com seus filhos. As razões para o tempo insuficiente alocado à educação dos filhos são as seguintes: sobrecarga de tarefas em casa e no trabalho; causas psicológicas de interação intergeracional; e razões externas, como estudo, saúde precária e necessidade de cuidar de outros parentes.

Resumen Este estudio intenta medir el tiempo asignado a los niños por medio de la autoevaluación de los padres y del criterio de suficiencia subjetiva o de insuficiencia de tiempo. Se encuestaron 545 padres rusos de la región de los Urales y se usó el análisis factorial para identificar los principales determinantes que afectan la autoevaluación del tiempo asignado a la crianza de los hijos. Descubrimos que en las regiones rusas los padres tienen la opinión común de que no pasan suficiente tiempo con sus hijos. Las razones para la cantidad insuficiente de tiempo asignado a la crianza de los hijos son la sobrecarga de deberes laborales en el hogar y en el trabajo, causas psicológicas de la interacción intergeneracional, o razones externas como estudio, mala salud o necesidad de cuidar a otros familiares.

How to collect non-medical data in a pediatric trial: diaries or interviews.

BACKGROUND: Non-medical data, such as the amount of time that patients and caregivers spend managing their condition, may be relevant when assessing therapeutic strategies. For chronic pediatric conditions, the time that patients and caregivers spend in seeking and providing care (which are the indirect costs in an economic evaluation) can be significantly different depending on the treatment arm. To explore methods for collecting information on the care burden for caregivers and patients, we investigated whether a patient diary provided additional information compared to retrospective investigator-led interviews and whether a diary that was completed intermittently produced more or less information than a diary completed continually. The main objective of this study was to identify which type of data collection was most effective for measuring the time spent by caregivers and for estimating indirect treatment costs over 9 months. METHODS: Start-In! is a randomized controlled trial comparing the efficacy of three strategies of real-time continuous glucose monitoring for 12 months in children and adolescents with type 1 diabetes. We designed an ancillary study to assess methods of collecting information on the time spent by patients and caregivers in managing their condition (indirect costs). Data were entered retrospectively in case report forms (CRFs) by investigators during quarterly follow-up visits, which were supplemented with diaries completed prospectively by children or caregivers either continuously or intermittently. Data about absences from school and work as well as the time that caregivers spent on diabetes care were collected and the three collection methods were compared. RESULTS: At the end of the 9-month study, 42% of the study participants failed to return their diary. For the diaries that were received, less than 10% of expected data were collected versus 82% during investigators'interviews. Based on all the information collected, we calculated that over 9 months, caregivers lost on average 3.9 days of working time (€786) and 4 days of personal time, i.e. the equivalent of €526, and spent around 15 min of time on care per day, i.e. the equivalent of €1700. CONCLUSIONS: The CRFs completed by investigators during quarterly visits cannot be replaced by a diary. Completing the diaries appeared to represent an important additional burden to children and their caregivers, and the diaries provided little additional information compared to investigators' entries in the CRF. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00949221. Registered on 30 July 2009. Registry name: Study of Insulin Therapy Augmented by Real Time Sensor in Type 1 Children and Adolescents (START-IN!).

Effect of pecuniary costs and time costs on choice of healthcare providers among caregivers of febrile children in rural Papua New Guinea.

BACKGROUND: User fees, transportation costs, and time costs impair access to healthcare by rural communities in low and middle income countries. However, effects of time costs on demand for healthcare are less understood than effects of user fees for health providers. In addition, prospective patients might not know about all health services available. This study aims to investigate how the family caregivers of febrile children respond to the pecuniary costs and time costs in their choice of health providers in rural Papua New Guinea. METHODS: Using an original questionnaire, we surveyed households in the catchment area surrounding Dagua Health Center in East Sepik Province, Papua New Guinea, during February-March 2015. We estimated the probability of choosing one among four categories of providers (i.e., the health center, aid posts, village health volunteers [VHVs], or home-treatment) via a mixed logit model in which we restrict alternatives to those for which family caregivers knew cost information. RESULTS: Of 1173 family caregivers, 96% sought treatment for febrile children from four categories of providers. Almost all knew the location of the health center and a health volunteer, but only 50% knew the location of aid posts. Analysis by discrete choice model showed that pecuniary costs and time costs were inversely associated with the probability of choosing any type of provider. We then changed pecuniary costs and time costs counterfactually to calculate and compare the probability of choosing each provider. Time costs affected the choice more than pecuniary costs, and individual heterogeneity appeared among caregivers with respect to pecuniary costs. When pecuniary or time costs of VHVs are altered, substitution between VHVs and home-treatment appeared. CONCLUSIONS: Our findings suggest that policies to increase awareness of aid posts and reduce time costs in addition to treatment fees for each category of healthcare provider could help developing economies to improve access to essential healthcare services.

[On the issue of work time measurement in phthisiatricians rendering ambulatory polyclinic care to adult and children population].

The formation of the number of medical personnel, the establishment of labor standards, the rational distribution and use of personnel are the most significant components of the system of labor rationing in health care. Standard norms of working time for TB doctors are not developed. There is an uneven workload and a plan implementation indicator in different offices and cabinets. The timing of the working process of phthisiatricians providing outpatient care to adults and children was carried out; work time was spent on individual elements of the labor process of district phthisiatricians accepting adults and children and a phthisiatrician without district work receiving patients in the office tuberculosis care for HIV patients. The concept of "visitation" is defined as applied to the working conditions of the TB service. According to the results of time-keeping observations, technological operations performed by TB doctors, including additional sections of work that are not related to the admission of patients, are highlighted; the normative indicator of the function of the medical post of the district TB specialist and the normative indicator of the time spent on one visit are determined.

Long-term cost of spouses' informal support for dependent midlife stroke survivors.

OBJECTIVES: Stroke is a major global disease that requires extensive care and support from society and relatives. The aim of this study was to identify and quantify the long-term informal support and to estimate the annual cost of informal support provided by spouses to their stroke surviving partner. METHOD: Data were based on the 7-year follow-up of the Sahlgrenska Academy Study on Ischemic Stroke. One-third of the spouses stated that they provided support to their stroke surviving partner. The magnitude of the support was assessed with a study-specific time-diary and was estimated for independent and dependent stroke survivors based on the scores of the modified Rankin Scale. To deal with skewed data, a two-part econometric model was used to estimate the annual cost of informal support. RESULT: Cohabitant dyads of 221 stroke survivors aged <70 at stroke onset were included in the study. Spouses of independent stroke survivors (n = 188) provided on average 0.15 hr/day of practical support and 0.48 hr/day of being available. Corresponding figures for spouses of dependent stroke survivors (n = 33) were 5.00 regarding practical support and 9.51 regarding being available. The mean annual cost of informal support provided for independent stroke survivors was estimated at €991 and €25,127 for dependent stroke survivor. CONCLUSION: The opportunity cost of informal support provided to dependent midlife stroke survivors is of a major magnitude many years after stroke onset and should be considered in economic evaluations of health care.

Centralised, decentralised or hybrid sanitation systems? Economic evaluation under urban development uncertainty and phased expansion.

Sanitation systems are built to be robust, that is, they are dimensioned to cope with population growth and other variability that occurs throughout their lifetime. It was recently shown that building sanitation systems in phases is more cost effective than one robust design. This phasing can take place by building small autonomous decentralised units that operate closer to the actual demand. Research has shown that variability and uncertainty in urban development does affect the cost effectiveness of this approach. Previous studies do not, however, consider the entire sanitation system from collection to treatment. The aim of this study is to assess the economic performance of three sanitation systems with different scales and systems characteristics under a variety of urban development pathways. Three systems are studied: (I) a centralised conventional activated sludge treatment, (II) a community on site source separation grey water and black water treatment and (III) a hybrid with grey water treatment at neighbourhood scale and black water treatment off site. A modelling approach is taken that combines a simulation of greenfield urban growth, a model of the wastewater collection and treatment infrastructure design properties and a model that translates design parameters into discounted asset lifetime costs. Monte Carlo simulations are used to evaluate the economic performance under uncertain development trends. Results show that the conventional system outperforms both of the other systems when total discounted lifetime costs are assessed, because it benefits from economies of scale. However, when population growth is lower than expected, the source-separated system is more cost effective, because of reduced idle capacity. The hybrid system is not competitive under any circumstance due to the costly double piping and treatment.

Foraging behavior and morphology: seed selection in the harvester ant genus, Pogonomyrmex.

Optimally foraging animals can be behaviorally or morphologically adapted to reduce the energetic and time costs of foraging. We studied the foraging behavior and morphology of three seed harvester ant species, Pogonomyrmex barbatus, P. desertorum, and P. occidentalis, to determine the importance of behavioral strategies and morphological features associated with load carriage in reducing the costs of foraging. We found that none of five morphological features we measured had a significant impact on seed selection. Also, body size did not influence running speed, an important variable in time costs of foraging. Temperature had the largest effect on running speed in these species. Our results show that these species have foraging strategies which minimize the time costs of traveling with seeds. We also describe a pattern where the running speed in individual-foraging species is less affected by increasing seed size than in trunk-trail foragers, when temperature and body mass are held constant. These results support previous work which showed that time costs are most important in seed selection for Pogonomyrmex, and suggest that central place foraging theory may need to accommodate variation in foraging strategy to more accurately predict optimal seed size selection in harvester ants.