A pilot study examining the unmet needs of cancer survivors living with polypathology.

With improved average longevity, the issue of polypathology in the cancer population is of growing importance, because it will increasingly affect more people. The present study piloted two self-report surveys aiming to provide preliminary data on the nature of polypathology and supportive care needs (met and unmet) of cancer survivors. Survivors were recruited from outpatient clinics at the Princess Margaret Hospital in Toronto and were asked to complete and give feedback on the surveys. Of a convenience sample of 88 survivors, almost three quarters (73%) reported having polypathology, and 64% had at least 1 unmet need. Results also suggest that those with the highest number of needs were more likely to have polypathology. Our study invites further assessments with self-report surveys of the complex picture that arises when cancer is not the only disease affecting a person. It also highlights the need for innovative supportive services to address patient needs.

Canadian survey on pandemic flu preparations.

BACKGROUND: The management of pandemic influenza creates public health challenges.An ethical framework, 'Stand on Guard for Thee: ethical considerations in pandemic influenza preparedness' that served as a template for the World Health Organization's global consultation on pandemic planning, was transformed into a survey administered to a random sample of 500 Canadians to obtain opinions on key ethical issues in pandemic preparedness planning. METHODS: All framework authors and additional investigators created items that were pilot-tested with volunteers of both sexes and all socioeconomic strata. Surveys were telephone administered with random sampling achieved via random digit dialing (RDD). Eligible participants were adults, 18 years or older, with per province stratification equaling provincial percent of national population. Descriptive results were tabulated and logistic regression analyses were used to assess whether demographic factors were significantly associated with outcomes. RESULTS: 5464 calls identified 559 eligible participants of whom 88.5% completed surveys. Over 90% of subjects agreed the most important goal of pandemic influenza preparations was saving lives, with 41% endorsing saving lives solely in Canada and 50% endorsing saving lives globally as the highest priority. Older age (OR = 8.51, p < 0.05) and current employment (OR = 9.48, p < 0.05) were associated with an endorsement of saving lives globally as highest priority. About 90% of respondents supported the obligation of health care workers to report to work and face influenza pandemic risks excepting those with a serious health condition that increased risks. Over 84% supported the government's provision of disability insurance and death benefits for health care workers facing elevated risk. Strong majorities favored stocking adequate protective antiviral dosages for all Canadians (92%) and, if effective, influenza vaccinations (95%). Over 70% agreed Canada should provide international assistance to poorer countries for pandemic preparation, even if resources for Canadians were reduced. While 92% of this group, believed provision should be 7 to 10% of all resources generated, 43% believed the provision should be greater than 10%. CONCLUSIONS: Results suggest trust in public health officials to make difficult decisions, providing emphasis on reciprocity and respect for individual rights.

The utility of publicly reported cancer treatment wait time information for patients and health care providers.

AIMS: To determine the utility of web-based radiation wait time information for patients and health care providers in decision-making. To revise the information using a simulated laboratory environment and to re-evaluate the new web-based information. MATERIALS AND METHODS: An online 'pop-up' survey on the Cancer Care Ontario (CCO) website measured user satisfaction. Qualitative data were gathered through patient focus groups and physician interviews. On the basis of the analysis, the website was revised and usability testing conducted. The information was re-evaluated by end-users through survey methodology. RESULTS: The majority accessing the wait time website were patients and family members. The modal age of use of the website was 31-50 years. Patients found the information more helpful after redesign than health professionals, but both found the language less easy to understand, highlighting the need to continuously evaluate the effectiveness of the website. Patients did not identify themselves as consumers of wait time information. Their expectation was that physicians would determine the urgency for treatment and would ensure timely access to care. Physicians reported that they did not use the CCO website on wait times and would not use the data for decision-making. Referrals were based on urgency of care and usual referral patterns. Referral patterns did not shift to centres with shorter wait times. CONCLUSIONS: The results of this study did not confirm the usefulness of the web-based wait time information for patients and physicians as a resource on how to obtain timely access to radiation treatment. Patients relied on their physician to manage their access to treatment according to the urgency of their clinical condition. Physicians preferred their established referral process rather than referring their patients to centres with shorter wait times. As patients become more computer savvy, it will be interesting to see if they increasingly become consumers of web-based wait time information.

Supporting cancer patients through the continuum of care: a view from the age of social networks and computer-mediated communication.

Almost since its inception, the Internet has been used by ordinary people to connect with peers and to exchange health-related information and support. With the rapid development of software applications deliberately designed to facilitate social interaction, a new era is dawning in which patients and their loved ones can collaboratively build knowledge related to coping with illness, while meeting their mutual supportive care needs in a timely way, regardless of location. In this article, we provide background information on the use of "one-to-one" (for example, e-mail), "one-to-many" (for example, e-mail lists), and "many-to-many" (for example, message boards and chat rooms, and more recently, applications associated with Web 2.0) computer-mediated communication to nurture health-related social networks and online supportive care. We also discuss research that has investigated the use of social networks by patients, highlight opportunities for health professionals in this area, and describe new advances that are fuelling this new era of collaboration in the management of cancer.

The path towards eHealth: obstacles along the way.

OBJECTIVES: The two authors of this article share both a strong interest in, and deep concerns about, the use of eHealth (electronic information and communication technologies for improving or maintaining health). In this article, we identify some unanticipated obstacles to effective use of eHealth. METHODS: We reflected upon the potential of information and communication technologies to transform the health system and its failure to achieve that potential. RESULTS: We chose seven obstacles: the insufficient emphasis on health in eHealth, the lack of time for reflection, the development of a fortress mentality, poor evaluation of efforts, lack of involvement of youth, inequity, and a parochial attitude that precludes economies of scale. Whenever possible, we provided examples of innovative initiatives that illustrate potential ways to meet our current challenges. CONCLUSION: We believe that the obstacles we describe in this article can be overcome. The impediments are not only technological, but also cognitive, financial and political. To succeed will require a major shift from our ethic of competition to one of generosity, commitment, and collaboration; enlightened, as opposed to narrow, self-interest.

Evidence-based decision making and asthma in the internet age: the tools of the trade.

At the dawn of the Information Age, the practice of evidence-based decision making (EBDM) is still hindered by many important barriers related to the decision makers, to the evidence per se or to the health system. Some of these barriers, particularly those related to the distillation, dissemination and packaging of research evidence, could be overcome by recent and ongoing developments in portable/wearable computers, internet appliances, multimedia and wireless broadband internet traffic. This article describes specific EBDM-related tools, with emphasis on internet-enabled "how to" books; and tools to improve the quality of reporting research, to formulate questions; to search for evidence; to access journals, systematic reviews and guidelines; to interact with organizations promoting EBDM; and to tailor evidence to individual cases. However, thinking that all barriers to the practice of EBDM could be solved by fancy information technology is naïve. Barriers related to the generation, interpretation, integration and use of the evidence demand more complex and perhaps unfeasible solutions, as overcoming them will require substantial changes in the structure of the health system, in the politics of science and in the way in which humans think and behave.

Evidence-based patient choice and consumer health informatics in the Internet age.

In this paper we explore current access to and barriers to health information for consumers. We discuss how computers and other developments in information technology are ushering in the era of consumer health informatics, and the potential that lies ahead. It is clear that we witness a period in which the public will have unprecedented ability to access information and to participate actively in evidence-based health care. We propose that consumer health informatics be regarded as a whole new academic discipline, one that should be devoted to the exploration of the new possibilities that informatics is creating for consumers in relation to health and health care issues.

Examining the evidence in anesthesia literature: a critical appraisal of systematic reviews.

UNLABELLED: Systematic reviews are structured reviews that use scientific strategies to reduce bias in the collection, appraisal, and interpretation of relevant studies. We undertook a systematic review of published systematic reviews in perioperative medicine to summarize the areas currently covered by this type of literature, to evaluate the quality of systematic reviews in this field, and to assess some of the methodologic and reporting issues that are unique to systematic reviews. Computerized bibliographic databases, citation review, and hand searches were performed to identify eligible articles. Quality was assessed using the Overview Quality Assessment Questionnaire. Eight-two systematic reviews were found. Reviews in perioperative medicine tended to evaluate prophylactic or therapeutic interventions. No differences were seen in quality between reviews published in anesthesia and nonanesthesia journals. Nearly half of all systematic reviews had only minor or minimal flaws; however, methods can be improved with expanded search strategies, use of least two reviewers to assess each study, use of validated methods to evaluate quality, and assessment of potential sources of bias. IMPLICATIONS: The quality of systematic reviews relating to perioperative medicine was examined systematically and found to be similar in quality to those in other specialties. Adoption of recently published criteria on writing and methods could further improve this type of literature.

What contributions do languages other than English make on the results of meta-analyses?

Including only a portion of all available evidence may introduce systematic errors into the meta-analytic process and threaten its validity. We set out to examine whether language restricted meta-analyses, compared to language inclusive meta-analyses, provide different estimates of the effectiveness of interventions evaluated in randomized trials. We identified and retrieved all 79 meta-analyses from several disease areas in which explicit eligibility criteria regarding trial selection were reported. General characteristics and quality of reporting of the meta-analyses were assessed using a validated instrument. We explored the effects of language of publication of the randomized trials on the quantitative results using logistic regression analyses. Language restricted meta-analyses, compared to language inclusive meta-analyses, did not differ with respect to the estimate of benefit of the effectiveness of an intervention (ROR = 0.98; 95% CI: 0.81-1.17). These results were also robust after a series of sensitivity analyses. This study provides no evidence that language restricted meta-analyses lead to biased estimates of intervention effectiveness. We encourage others to replicate this study using different sampling frames, clinical topics and interventions.

Does locoregional radiation therapy improve survival in breast cancer? A meta-analysis.

PURPOSE: Recent randomized trials in women with node-positive breast cancer who received systemic treatment report that locoregional radiation therapy improves survival. Previous trials failed to detect a difference in survival that results from its use. A systematic review of randomized trials that examine the effectiveness of locoregional radiation therapy in patients treated by definitive surgery and adjuvant systemic therapy was conducted. METHODS: Randomized trials published between 1967 and 1999 were identified through MEDLINE database, CancerLit database, and reference lists of relevant articles. Relevant data was abstracted. The results of randomized trials were pooled using meta-analyses to estimate the effect of treatment on any recurrence, locoregional recurrence, and mortality. RESULTS: Eighteen trials that involved a total of 6,367 patients were identified. Most trials included both pre- and postmenopausal women with node-positive breast cancer treated with modified radical mastectomy. The type of systemic therapy received, sites irradiated, techniques used, and doses of radiation delivered varied between trials. Data on toxicity were infrequently reported. Radiation was shown to reduce the risk of any recurrence (odds ratio, 0.69; 95% confidence interval [CI], 0.58 to 0.83), local recurrence (odds ratio, 0.25; 95% CI, 0.19 to 0.34), and mortality (odds ratio, 0.83; 95% CI, 0.74 to 0.94). CONCLUSION: Locoregional radiation after surgery in patients treated with systemic therapy reduced mortality. Several questions remain on how these results should be translated into current-day clinical practice.

Systematic reviews and meta-analyses on treatment of asthma: critical evaluation.

OBJECTIVE: To evaluate the clinical, methodological, and reporting aspects of systematic reviews and meta-analyses on the treatment of asthma and to compare those published by the Cochrane Collaboration with those published in paper based journals. DESIGN: Analysis of studies identified from Medline, CINAHL, HealthSTAR, EMBASE, Cochrane Library, personal collections, and reference lists. STUDIES: Articles describing a systematic review or a meta-analysis of the treatment of asthma that were published as a full report, in any language or format, in a peer reviewed journal or the Cochrane Library. MAIN OUTCOME MEASURES: General characteristics of studies reviewed and methodological characteristics (sources of articles; language restrictions; format, design, and publication status of studies included; type of data synthesis; and methodological quality). RESULTS: 50 systematic reviews and meta-analyses were included. More than half were published in the past two years. Twelve reviews were published in the Cochrane Library and 38 were published in 22 peer reviewed journals. Forced expiratory volume in one second was the most frequently used outcome, but few reviews evaluated the effect of treatment on costs or patient preferences. Forty reviews were judged to have serious or extensive flaws. All six reviews associated with industry were in this group. Seven of the 10 most rigorous reviews were published in the Cochrane Library. CONCLUSIONS: Most reviews published in peer reviewed journals or funded by industry have serious methodological flaws that limit their value to guide decisions. Cochrane reviews are more rigorous and better reported than those published in peer reviewed journals.