Effects of physician outreach programs on rural-urban differences in breast cancer management.

In 1986 to 1987, urban-rural differences in several breast cancer management practices were noted in Illinois data. Several intervention programs for physicians were initiated to improve rural patients' access to state-of-the-art breast cancer management to reduce these differences. This report compares an intensive rural oncology outreach intervention program with a lower intensity physician education program. Medical records from 1986 to 1991 were reviewed on 2,277 breast cancer patients in a 12-county study area. The care received by urban patients was compared with three groups of rural patients: those managed in rural hospitals with intensive oncology outreach programs beginning in 1988 (Rural group 1), and in those rural hospitals with less intensive interventions using an audit with feedback strategy beginning in 1989 (Rural group 2). Rural patients who traveled to one of the urban facilities also were included in the analysis because the less intensive interventions also took place in these facilities, and these patients showed unique patterns of care in the baseline analysis (Rural Group 3). The years 1986 to 1987 constituted the baseline, and 1990 to 1991 constituted the final evaluation period. Chi square and multivariate analyses were conducted to compare the effect of the two types of interventions on changing breast cancer management practices and reducing the urban-rural differences. By the final evaluation period, the high intensity intervention was not more successful in reducing or eliminating the urban-rural differences than the low intensity intervention for many practices. However, often the frequency estimates were higher in Rural Group 1, which received the high intensity intervention. The changes noted in Rural Group 3 were not always the same as in Rural Group 2, even though both received the same low intensity interventions, lending evidence to the observation that travel distance and other nonmedical factors affect the choices of management modalities for these patients. Finally, given the nonrandomized study design, other explanations for the changes could not be ruled out.

Cancer care critical pathways: implementing a successful program.

Change in any form creates stress on systems, yet there is growing awareness within the health care field that change must come as cost-conscious insurers and employers refuse to pay for overextended processes that grew out of the charge-based reimbursement era. Short-term solutions, such as discounted charges and staff cuts, are not the answer when the entire system needs an overhaul. The cost of care escalates and the quality of patient care suffers because the system lacks the appropriate mechanisms to reduce redundancy, eliminate waste, improve effectiveness, and provide the high-quality care that a community expects from its hospital. The outcomes-based critical pathway approach discussed here has been used with great success and differs from classic pathway writing in that only elements related to the specific outcome are allowed on the order set. The critical pathway process starts with a review of historical patient records, which yields information about both historical practice patterns and the provider team. Using this information, a work group is formed and patient goals or outcomes are established for the population in question. The entire system is informed and educated, with special attention given to the medical staff, clinical outcome and financial data are developed and provided to individuals in the process, and a feedback loop is established. Cancer care is an attractive target for critical pathways, because it is an area with high cost and expensive technology, and physician practice patterns and patient outcomes can vary widely. On the flip side, the historically multidisciplinary nature of cancer care offers a good starting point for the collaborative culture needed to successfully implement critical pathways. When done right, critical pathways can decrease morbidity and mortality, reduce redundancy and cost, increase patient satisfaction, and improve patient outcomes. Shifting practice and eliminating variation in practice patterns, without regard to best practices and outcomes, could leave an organization compromised by group norms. Few things will sustain the energy needed to keep the hospital culture moving forward. This is not to say that it cannot be done, because it can. The critical pathway process has noticeable energy cycle levels--periods of high energy and low energy. The two hospitals discussed here reveal their painstaking effort to maintain and invigorate a process that would rather wait another day. Carefully selected work group members, reminders to keep individuals from returning to old practice habits, and an established, firm connection between cost and quality will help carry an organization through periods of low energy.(ABSTRACT TRUNCATED AT 400 WORDS)

Education of rural physicians about breast cancer through an oncology outreach program.

In 1990, the Rural Illinois Cancer Consortium initiated an intervention in the management of breast cancer for all rural hospitals. Regional data from a 12-county area were used to identify issues and develop an intervention emphasis. The data suggested two management issues: eliminate unilateral diagnostic mammography and increase the number of patients that have their tumor staged. The intervention involved seminars to provide feedback to physicians on management of breast cancer patients in the region. A series of personalized mailings emphasizing the intervention message were also deployed. Although data are not yet available to measure the intervention impact, immediate feedback on the interventions was sought through a physician survey and several process measures. The immediate feedback measures were assessed. These measures were the penetration of the rural hospital seminars, physician behavior self-reported by mail survey, and number of inquiries to the Physician Data Query. Each of the nine hospitals held a seminar, and 39 percent of the rural physicians treating breast cancer patients attended. Survey data showed physician behavior change in the desired direction, compared with data from the baseline medical record audit conducted in 1986-87. Intervention feedback was useful in defining the implementation success of the interventions. The outcome evaluation, based on medical record audits, is in progress.

Age differences in the breast cancer management of rural women.

This article describes the effect of age on the pattern of access to breast cancer care among rural women diagnosed in 1986-1989. Cases were identified by the Illinois State Cancer Registry and information on breast cancer management was obtained through review of hospital records and physician survey. Case follow-back was more than 99% complete. State-of-the-art breast cancer management was defined by the Physician Data Query (PDQ) and included diagnostic evaluation, prognostic evaluation, and stage-specific definitive treatment. The data did not indicate age differences in bilateral diagnostic mammography, performance of hormone receptor assays, radiation therapy, and stage-appropriate treatment. Tumor staging and axillary node dissection did differ by age with significant negative trends in the multivariate model. Also, women younger than 55 years were the most likely to receive separate diagnostic biopsy, limited surgery, and chemotherapy, whereas women 55 to 74 years were most likely to receive hormone therapy. Although rural populations may experience barriers to some aspects of state-of-the-art breast cancer management, age does not always exacerbate them.

Clinical assessment of 111In-CYT-103 immunoscintigraphy in ovarian cancer.

The ability of 111In-CYT-103 immunoscintigraphy to aid in the diagnosis of patients with primary or recurrent/residual ovarian cancer was evaluated in a multicenter trial. The 111In-labeled immunoconjugate of the monoclonal antibody B72.3 was prepared using a site-specific conjugation method. A total of 103 patients received a 1 mg infusion of 111In-CYT-103 and subsequently underwent surgery or biopsy. The infusion of 111In-CYT-103 was well tolerated; only 1 patient experienced a modest elevation in blood pressure that was likely related to the infusion. 111In-CYT-103 immunoscintigraphy correctly identified surgically confirmed tumor in 68% of patients with ovarian adenocarcinoma. The sensitivity of 111In-CYT-103 immunoscintigraphy was positively influenced both by the size of the tumor lesion and the tumor TAG-72 antigen expression. The overall sensitivity of 111In-CYT-103 immunoscintigraphy was greater than that of CT imaging (44%). Antibody imaging detected occult disease in 20 of 71 patients with surgically documented ovarian adenocarcinoma; 6 patients being evaluated after initial surgery and chemotherapy had an otherwise negative presurgical workup and a normal CA 125 serum level. The results of this trial also indicate that 111In-CYT-103 immunoscintigraphy can contribute to the medical and surgical management of some patients with ovarian cancer. The results of this trial indicate that 111In-CYT-103 immunoscintigraphy should be a valuable addition to the presurgical evaluation of patients with suspected persistent or recurrent ovarian cancer.

Urban-rural differences in the management of breast cancer.

We conducted a population-based study with medical-record review of breast cancer patients as part of a larger study of an oncology outreach program to improve cancer management for rural patients within their community hospital. This analysis compares the breast cancer care received by the rural population before the oncology outreach program with that of the contiguous urban population. All 1986-87 cases in selected Illinois (United States) counties were identified using the Illinois State Cancer Registry. Data were obtained by hospital record audit and physician survey. Case follow-back was 98 percent complete. Rural cases were evaluated separately when they were diagnosed in an urban facility. State-of-the-art management was defined by the 1986-87 Physician Data Query and included diagnostic evaluation, prognostic evaluation, and stage-specific treatment. A summary variable incorporated whether or not the most appropriate management was offered. Compared with urban cases, rural cases diagnosed in rural hospitals were less likely to have staged tumors and more likely to have node dissections. Rural cases traveling to urban centers were less likely to have limited surgery, hormone therapy, and a biopsy as a first-step surgical procedure, and more likely to have node dissection.

Immunoscintigraphy of colorectal carcinoma utilizing 111In-labeled monoclonal antibody conjugate CYT-103.

Twelve presurgical patients with colorectal carcinoma received a single intravenous infusion of 0.5-20.0 mg of the radiolabeled monoclonal antibody conjugate CYT-103. This product is an immunoconjugate of B72.3 labeled with Indium-111 (111In). Patients underwent preoperative gamma camera imaging and computed tomographic (CT) scanning of the abdomen and pelvis. Fifteen intraabdominal sites of tumor were found at surgery. Monoclonal antibody imaging detected 87% of these lesions, whereas CT of the abdomen and pelvis detected 47%. Monoclonal antibody imaging identified tumor in 27% of the patients in which CT did not identify any sites of tumor. The results of this study indicate that monoclonal antibody imaging using [111In]CYT-103 is useful for the preoperative evaluation of colorectal carcinoma patients and the results are complimentary to CT of the abdomen and the pelvis.