Cost-effectiveness analysis of intraoperative radiation therapy for early-stage breast cancer.

BACKGROUND: Shortened courses of radiation therapy have been shown to be similarly effective to whole-breast external-beam radiation therapy (WB-EBRT) in terms of local control. We sought to analyze, from a societal perspective, the cost-effectiveness of two radiation strategies for early-stage invasive breast cancer: single-dose intraoperative radiation therapy (IORT) and the standard 6-week course of WB-EBRT. METHODS: We developed a Markov decision-analytic model to evaluate these treatment strategies in terms of life expectancy, quality-adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio over 10 years. RESULTS: IORT single-dose intraoperative radiation therapy was the dominant, more cost-effective strategy, providing greater quality-adjusted life years at a decreased cost compared with 6-week WB-EBRT. The model was sensitive to health state utilities and recurrence rates, but not costs. IORT was either the preferred or dominant strategy across all sensitivity analyses. The two-way sensitivity analyses demonstrate the need to accurately determine utility values for the two forms of radiation treatment and to avoid indiscriminate use of IORT. CONCLUSIONS: With less cost and greater QALYs than WB-EBRT, IORT is the more valuable strategy. IORT offers a unique example of new technology that is less costly than the current standard of care option but offers similar efficacy. Even when considering the capital investment for the equipment ($425 K, low when compared with the investments required for robotic surgery or high-dose-rate brachytherapy), which could be recouped after 3-4 years conservatively, these results support IORT as a change in practice for treating early-stage invasive breast cancer.

Measuring communication in the surgical ICU: better communication equals better care.

BACKGROUND: The Joint Commission on the Accreditation of Healthcare Organizations reports that communication breakdowns are responsible for 85% of sentinel events in hospitals. Patients in surgical ICUs are the most vulnerable to communication errors. Fellows and residents are an integral part of the surgical ICU team, but little is known about resident-fellow communication and its impact on surgical ICU patient outcomes. The objective of this study is to describe resident-fellow patient care communication patterns in the surgical ICU and correlate established communication patterns with short-term outcomes. STUDY DESIGN: A prospective observational trial was conducted for 136 consecutive surgical ICU days. We evaluated resident-fellow communication of four cardiorespiratory events: hypotension, new arrhythmias, tachypnea, and desaturation. We prospectively defined three short-term outcomes: improved, not improved, and worse. An intervention was attempted to improve communication. RESULTS: Three hundred twelve events were collected (166 observational and 146 interventional). PGY3 residents covered approximately 60% of days in both phases. PGY3 residents were responsible for 73% of communication errors in the observational phase and 59% of communication errors in the interventional phase. Communication errors were more likely in the late shift (p < 0.0001). The late shift was responsible for 77% of all communication errors. Communication errors resulted in worse short-term outcomes for cardiorespiratory events (p < 0.0002). Effective communication was a significant predictor of improved short-term outcomes (p < 0.0003). The intervention decreased communication errors in the late shift by 10% (p < 0.052). CONCLUSIONS: Communication errors occurred more frequently during the late shift. These communication errors were associated with worsened short-term outcomes. Improved communication in the surgical ICU is a fruitful target to improve clinical outcomes.