Alerting surgeons when their breast cancer patients did not attend a follow-up consultation with a medical oncologist was associated with a reduction in racial disparities in adjuvant therapy, according to a non-randomized study published in the November 25 online issue of the Journal of the National Cancer Institute.

Black and Hispanic women with early stage breast cancer are less likely to consult a medical oncologist than their white counterparts. To reduce system failures in which the surgeon recommends a consultation and the patient does not refuse but still does not receive the consultation, Nina Bickell, M.D., of the Mount Sinai School of Medicine in New York and colleagues implemented a tracking and feedback system in six New York hospitals.

In the current study, Bickell and colleagues compared the rate of completed consultations with a medical oncologist and the use of adjuvant therapy among 639 women with early stage breast cancer who were treated between 1999 and 2000, prior to implementation of the system, with 300 women treated between 2004 and 2006 after implementation.

The researchers found that the tracking and feedback registry was associated with a 14 percentage point increase in consultations with oncologists, from 83 percent in the pre-implementation group to 97 percent in the post-implementation group. There was a statistically significant decrease in the underuse of adjuvant treatment, from 23 percent in the earlier cohort to 14 percent in the later cohort. The decline in underuse of adjuvant care was more pronounced in black (34 percent to 14 percent) and Hispanic women (23 percent to 13 percent) than in white women (17 percent to 14 percent).

“The tracking and feedback registry, designed to target the system failure cause of underuse, was most effective at municipal hospitals that had greater frequencies of underuse due to system failure,” the authors write. “Especially in such settings, this simple intervention appeared to eliminate previously detected racial disparities in adjuvant treatment underuse.”

In an accompanying editorial, Rachel Freedman, M.D., and Eric P. Winer, M.D., of the Dana-Farber Cancer Institute in Boston note that because breast cancer care requires patients to see multiple specialists over the course of their therapy, there are opportunities for patients to get lost in the system. Navigator programs have already been implemented in numerous hospitals to help patients move through health care systems as smoothly as possible. A tracking and feedback system, such as the one used in the Bickell study, may have the potential to improve care, but randomized studies need to be performed to more definitively demonstrate the effectiveness of such programs.

“We believe that the work described by Bickell et al., albeit promising, needs to be replicated using a prospective, randomized design,” the editorialists write. “Disparities in cancer care represent one of the most important challenges facing the oncological community, and although we need to act quickly, we cannot rush to implement approaches that have not been thoroughly evaluated through rigorous investigation.”

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Citation:

Article: Bickell NA, et al. A Tracking and Feedback Registry to Reduce Racial Disparities in Breast Cancer Care. Journal of the National Cancer Institute 2008; 100:1717-1723

Editorial: Freedman RA, Winer EP. Reducing Disparities in Breast Cancer Care – A Daunting but Essential Responsibility. Journal of the National Cancer Institute 2008; 1661-1663

The Journal of the National Cancer Institute is published by Oxford University Press and is not affiliated with the National Cancer Institute. Visit the Journal online at jnci.oxfjnci.oxfordjournals/ordjournals/.

Source: Liz Savage
Journal of the National Cancer Institute

President-elect Barack Obama has promised to provide health insurance for every child in America. How will that be achieved? If recent history is instructive, it will not be by creating a single, egalitarian system.

Instead, we will most likely create a two-tiered system – a publicly funded safety net for people of lower incomes, and a private market in health insurance for those who can afford it. That’s according to John Lantos, MD, author of a commentary on the issue in October’s Archives of Pediatrics & Adolescent Medicine.

Dr. Lantos served on the Task Force on National Health Care Reform chaired by then First Lady Hillary Clinton in the early 1990s. Currently, he is the John B. Francis Chair in Bioethics at the Center for Practical Bioethics in Kansas City.

Link: Abstract, Four Recent Health Reform Initiatives: Implications for Pediatric Health Reform, Archives of Pediatrics & Adolescent Medicine, October 2008

Source
Lorell R. LaBoube
Center for Practical Bioethics

Ventricular assist devices, or VADs – surgically-placed mechanical pumps that can support failing hearts or buy time to transplant – are associated with high hospital costs and high rates of early death among Medicare recipients, say researchers at Duke University Medical Center.

Their study, appearing in the November 26 issue of the Journal of the American Medical Association, found that only half of all patients who received a VAD were alive one year later.

“This study tells us two things,” says Adrian Hernandez, M.D. a cardiologist at Duke and the lead author of the study. “VADs are an emerging technology and while they have been proven effective in extending life, more needs to be done before they can be more widely adopted in patients with heart failure. Also, as physicians, we need to do a better job defining the time of optimal intervention and identifying who is most likely to benefit from a VAD.”

Researchers analyzed data on nearly 3,000 Medicare patients who received a VAD between 2000 and 2006, measuring hospitalization and death rates and tracking inpatient costs. Half the patients received a VAD as a primary strategy for treatment of heart failure and the other half received a VAD after cardiac surgery.

Among the primary group, 55 percent of patients were discharged alive with a VAD after a median hospital stay of 30 days. By one year, 20 percent of the primary group had undergone transplant, 5 percent had the device removed, 42 percent had died and 32 percent were alive with the device.

In the post-surgical group, a third were discharged alive with a device, and the median hospital stay was 10 days. At one year, a quarter of the group was alive with a VAD in place.

Investigators also found that care did not end with the initial hospitalization. About half the patients in both groups had to be re-hospitalized within six months. Mean Medicare hospital costs for the primary group neared $200,000, but the cost for patients in the post-surgery group was closer to $100,000.

“The figures are somewhat discouraging, but we have to remember that all of these are very high-risk patients to begin with. They were elderly and in grave condition because of their failing hearts. Without a VAD, they probably would not have survived,” says Hernandez.

The average age of the patients was 63 in the primary group and 69 in the post-surgery group. Hernandez says survival rates are somewhat better among younger, healthier patients.

The study also suggests that outcomes may depend, in part, on where VAD procedures are performed. Researchers identified 570 hospitals that implanted VADs, but more than half the hospitals implanted only one VAD per year. As with other surgical procedures, volume appears to matter. Higher volume was significantly associated with lower risk of death, with risk of death 31 percent lower in hospitals performing at least five procedures per year.

“This suggests there may be an opportunity to improve outcomes by simply organizing VAD care around centers with significant experience, says Hernandez. “It may make sense to designate certain hospitals as ‘centers of excellence,’ where VAD procedures are routine and patients could benefits from their expertise.”

The study is the first to examine trends in the use of assist devices after Medicare moved in 2003 to expand their use among elderly patients with certain end-stage characteristics. While it may raise questions about the value of using expensive, high-end technologies in fragile patients at the end of life, Hernandez says it would be short-sighted to dismiss VADs as too risky. “As a technology, VADs are still evolving. We have a lot to learn about how to use them and when to use them. As our collective experience grows, we feel confident that patients’ outcomes will improve.”

Lesley Curtis, PhD, a health services researcher in the Duke Clinical Research Institute and senior author of the study, says the study also points to a growing need to balance the development and use of new technologies in an era of limited resources. “This is not about turning away from a promising new technology. It’s about choosing the right patient for the right device at the right time.”

###

Additional authors include Eric Peterson, Kevin Schulman, Christopher O’Connor, Joseph Rogers, Carmelo Milano, Alisa Shea and Bradley Hammill, all from Duke.

Source: Michelle Gailiun

Duke University Medical Center

If climate disasters are to be averted, atmospheric carbon dioxide (CO2) must be reduced below the levels that already exist today, according to a study published in Open Atmospheric Science Journal by a group of 10 scientists from the United States, the United Kingdom and France.

The authors, who include two Yale scientists, assert that to maintain a planet similar to that on which civilization developed, an optimum CO2 level would be less than 350 ppm – a dramatic change from most previous studies, which suggested a danger level for CO2 is likely to be 450 ppm or higher. Atmospheric CO2 is currently 385 parts per million (ppm) and is increasing by about 2 ppm each year from the burning of fossil fuels (coal, oil, and gas) and from the burning of forests.

“This work and other recent publications suggest that we have reached CO2 levels that compromise the stability of the polar ice sheets,” said author Mark Pagani, Yale professor of geology and geophysics. “How fast ice sheets and sea level will respond are still poorly understood, but given the potential size of the disaster, I think it’s best not to learn this lesson firsthand.”

The statement is based on improved data on the Earth’s climate history and ongoing observations of change, especially in the polar regions. The authors use evidence of how the Earth responded to past changes of CO2 along with more recent patterns of climate changes to show that atmospheric CO2 has already entered a danger zone.

According to the study, coal is the largest source of atmospheric CO2 and the one that would be most practical to eliminate. Oil resources already may be about half depleted, depending upon the magnitude of undiscovered reserves, and it is still not practical to capture CO2 emerging from vehicle tailpipes, the way it can be with coal-burning facilities, note the scientists. Coal, on the other hand, has larger reserves, and the authors conclude that “the only realistic way to sharply curtail CO2 emissions is phase out coal use except where CO2 is captured and sequestered.”

In their model, with coal emissions phased out between 2010 and 2030, atmospheric CO2 would peak at 400-425 ppm and then slowly decline. The authors maintain that the peak CO2 level reached would depend on the accuracy of oil and gas reserve estimates and whether the most difficult to extract oil and gas is left in the ground.

The authors suggest that reforestation of degraded land and improved agricultural practices that retain soil carbon could lower atmospheric CO2 by as much as 50 ppm. They also dismiss the notion of “geo-engineering” solutions, noting that the price of artificially removing 50 ppm of CO2 from the air would be about $20 trillion.

While they note the task of moving toward an era beyond fossil fuels is Herculean, the authors conclude that it is feasible when compared with the efforts that went into World War II and that “the greatest danger is continued ignorance and denial, which could make tragic consequences unavoidable.”

“There is a bright side to this conclusion” said lead author James Hansen of Columbia University, “Following a path that leads to a lower CO2 amount, we can alleviate a number of problems that had begun to seem inevitable, such as increased storm intensities, expanded desertification, loss of coral reefs, and loss of mountain glaciers that supply fresh water to hundreds of millions of people.”

In addition to Hansen and Pagani, authors of the paper are Robert Berner from Yale University; Makiko Sato and Pushker Kharecha from the NASA/Goddard Institute for Space Studies and Columbia University Earth Institute; David Beerling from the University of Sheffield, UK; Valerie Masson-Delmotte from CEA-CNRS-Universite de Versaille, France Maureen Raymo from Boston University; Dana Royer from Wesleyan University and James C. Zachos from the University of California at Santa Cruz.

Citation: Open Atmospheric Science Journal, Volume 2, 217-231 (2008)

Links:

Mark Pagani
geology and geophysics
Robert Berner
Open Atmospheric Science Journal

Yale University

New research, just published by researchers from the University of Georgia, provides the first evidence that a key gene may be crucial to maintaining the production of the thymus and its disease-fighting T-cells after an animal’s birth.

The discovery could help scientists find out how to turn the thymus back on so it could produce T-cells long after it normally shuts down most of its function, which, for humans, occurs by early adulthood. If the finding leads to further ways to manipulate the gene, the result could be a new avenue for the body to fight disease more effectively as the body ages.

The research was just published in the online edition of the journal Blood, a publication of the American Society of Hematology.

“Such things as infectious diseases, inflammation and heart problems are all related to immune response,” said Nancy Manley, an associate professor of genetics and chair of UGA’s Interdepartmental Developmental Biology Group. “You don’t have to think far to see how understanding the effect of this gene could affect the quality of life for older people and others as well.”

Other authors of the paper, beside Manley, are doctoral graduate student Lizhen Chen and assistant research scientist Shiyun Xiao, also of the University of Georgia.

The thymus is an organ located in the upper part of the human chest cavity, behind the sternum. This organ is the location where important systemic infection fighters called T-cells develop. Over the past two decades, T-cell counts have become part of everyday dialogue due to their importance in monitoring HIV/AIDS and other disorders.

The thymus slowly begins to shut down early in life and becomes largely inactive by early adulthood. Still, that’s fine for most people, since an entire lifetime supply of T-cells is produced in that time. But, for some people, the loss of irreplaceable T-cells through disease can lead to chronic illnesses and a shortened life.

Until recently, scientists had thought that the thymus in adults was permanently shut down because no known regulatory mechanism existed that might allow doctors to “turn back on” the thymus if a person’s T-cells were compromised. There are now some treatments currently in trials that can transiently rejuvenate the thymus and increase thymic output in humans.

The problem has been, though, that the mechanisms by which all this works are poorly understood, and all current treatments have systemic effects that can cause unacceptable side effects in all but the most seriously ill, who are more willing to tolerate them in exchange for possible benefit.

Now, however, Manley and her colleagues have shown for the first time that a gene called Foxn1 is required to maintain the postnatal thymus. Their results also suggest that changes in Foxn1 expression in important thymic epithelial cells (TECs) during aging contribute to the slow shut-down of the thymus with age.

“While this research was done in mice, it’s not far-fetched to say that this points toward possible therapies for a huge variety of illnesses, from AIDS to age-related immunodeficiency disorders,” said Manley.

One clear advantage of understanding how Foxn1 works in maintaining the thymus and T-cell production is that it could lead to narrowly targeted therapies that are less likely to cause collateral side effects in a patient.

Manley got into studying the Foxn1 gene through her work as a developmental biologist, but the discovery of how the gene works in maintaining the postnatal thymus came as a surprise. The mouse carrying the genetically altered Foxn1 gene was produced by happenstance rather than by design. It turns out that the engineered gene has normal fetal expression and thymus development, but after birth, the gene’s expression decays much more rapidly than in normal mice, giving the scientists a way to rapidly assess just what the gene does in the growing animal.

“In effect, what happens in this model is that the gene ‘ages’ more rapidly than the mouse does,” said Manley. “This has given us a tremendous ability to understand to a more accurate degree just what the gene is doing.”

The irony that the new discovery may find its best uses in dealing with issues of aging and that Manley is a development biologist hasn’t been lost on her.

“The truth is that aging and development aren’t really different things,” she said. “They’re part of a continuum. The young thymus is like a turned-on spigot pumping out a diversity of T-cell types, and T-cells live a long time. Even after the spigot turns off, we don’t really see any major changes in them for most people until they reach about 60 years of age. Then the rates of things like rheumatoid arthritis and cancer go up substantially. And, as we all know, older people get sick more often.”

If, however, physicians were able selectively to turn T-cell production back on, then many diseases that currently afflict older people could become manageable if not, in cases, entirely absent. So if “60 is the new 40,” as some people now say, that could theoretically change to “75 is the new 40.” And that first number of the pair could be even higher.

“Would turning Foxn1 back on allow us to regenerate an aged thymus?” Manley asks. “We just don’t know yet. But we are getting evidence now to say that it would allow it, and we will be working on that to see how it can happen. If we could delay when the thymus shuts off or have it work at a low level our entire lives, it has the potential to make a huge difference in so many health-related issues.”

While the mouse model doesn’t precisely mimic human response, it is close enough so that biologists and geneticists can often draw conclusions from mouse trials on how humans will respond.

Though the ability of science to manipulate this gene and potentially the production of T-cells isn’t going to happen next week, it may not be that far down the road, either. Under best circumstances, the researchers should know within five to 10 years whether the therapeutic ability to turn back on the production of T-cells is possible.

University of Georgia

Catharine, who works at Sheffield Children’s NHS Foundation Trust, was chosen from hundreds of nominations to appear in Extraordinary, a book by NHS Employers launched earlier this month.

The unique publication is the climax to NHS Employers’ ‘Extraordinary’ campaign celebrating the NHS 60th anniversary and features stories from 60 NHS staff from across the country.

Catharine said: “It is a great honour to be chosen for this book. I am just one of thousands of colleagues in Sheffield striving to the deliver the best possible care. The NHS is one this country’s greatest accomplishments and I am extremely proud to be part of it.”

Catharine joined the NHS in 1988 as a House Officer having completed medical school and was passionate about the specialty from the outset.

“I was the only student who chose to do a work attachment in the field! I loved it. It’s a specialty that’s practical and instantaneous. It’s a bit like a chemistry experiment – you put something in and get an instant reaction. You’re constantly doing things and you have a lot of control and responsibility.

“The most rewarding thing about the job is getting a child safely through an operation. Seeing them smile afterwards and being thanked by the parents is really satisfying.

“We really do work as a team at the Children’s Hospital. Everyone thinks they’re the ones in control of the theatre – anaesthetists, surgeons, scrub nurses, operating department practitioners. Yet when you can stick out your hand and the instrument you want will be put in it without having to ask, you know you’re working well together.”

Alastair Henderson, joint-director of NHS Employers, said: “Catharine was chosen for her wonderful contribution to today’s health service. With the other stories in the book, she represents the 1.3 million ordinary people doing extraordinary things in today’s health service.”

You can read Catharine’s story in Extraordinary which is available to buy at nhsemployers.

Photo of Catharine Wilson holding award.

Source
Sheffield Children’s Hospital
sheffieldchildrens.nhs

The alarming news reports concerning high-profile victims of personal medical information security and privacy breaches raises the bar on the necessity to educate and inform healthcare professionals, their employers, the media, and healthcare consumers on the importance of privacy protection, confidentiality and security of personal health records.

“It’s critical for healthcare professionals to receive more education about good privacy practices and appropriate interpretation of HIPAA and other regulations,” said American Health Information Management Association (AHIMA) President Wendy Mangin, director of medical records and privacy officer at Good Samaritan Hospital in Vincennes, Indiana.

Educating healthcare professionals on privacy and security issues is an ongoing concern within the health information industry. Recently, AHIMA’s House of Delegates voted to approve a resolution that asked AHIMA members to call on healthcare organizations to educate users of health information about the need for improved and consistent patient privacy and security; that health information management professionals be on the forefront of educating about auditing and monitoring access to health information; and that AHIMA endorse consistent healthcare policies and standards when a breach does occur.

AHIMA recognizes the public’s right to accurate and confidential personal health information and the need for advanced practices, processes and standards which safeguard their medical records.

About AHIMA

The American Health Information Management Association is America’s leading professional society whose mission is to “improve healthcare by advancing best practices and standards for health information management and [serve as] the trusted source for education, research and professional credentialing.” AHIMA represents more than 52,000 specially educated HIM professionals who serve healthcare and the public by managing, analyzing and utilizing data vital for health system management.

AHIMA

Most women in rural Zambia deliver their babies at home without skilled care because of the long distances involved in reaching emergency obstetric care, so it is crucial to address the geographic and quality barriers to health care use. These are the key findings from a study by Sabine Gabrysch from Ruprecht-Karls-UniversitГ¤t, Heidelberg, Germany and colleagues at the London School of Hygiene & Tropical Medicine published in this week’s PLoS Medicine.

In sub-Saharan Africa, a woman’s lifetime risk of dying during or following pregnancy is as high as 1 in 31 (compared to 1 in 4,300 in the developed world). Most maternal and newborn deaths in low-income countries could be prevented if all women delivered their babies in settings where skilled birth attendants (such as midwives) were available to provide emergency obstetric care to both mothers and babies if complications arise. Yet every year, roughly 50 million women worldwide give birth at home without a skilled attendant. Although poor geographic access to quality health care is likely to be a key issue for women, it has not received much attention so far.

The authors used a geographic information system and linked national household data with national health facility data to calculate straight-line distances between women’s villages and health facilities. They found that only a third of births in rural Zambia occurred at a health facility, and half of all mothers lived more than 25 km from a health facility that provided basic emergency obstetric care. As distance to the closest delivery facility doubled, the odds of a woman giving birth in a health facility decreased by 29%. The level of care at the facility also had a strong influence: If the closest facility provided basic emergency obstetric care as opposed to substandard services, the odds of facility delivery were 1.5 times higher and if it provided comprehensive emergency obstetric care, they were 2.5 times higher.

The authors say: “This study clearly shows that it is important to consider the health service environment when studying use of delivery services, as both distance to services and their quality are important determinants. Ignoring these influential factors can lead to an incomplete picture and invalid conclusions.” They add: “Our innovative approach of linking large-scale datasets using geographic coordinates could be applied beneficially also in other settings and fields.”

Funding: This work was done using existing data without particular funding. Funders thus had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. (Salary support for OC and SC was provided by LSHTM. SG was supported by a Graduate Teaching Assistantship of LSHTM until September 2009 and subsequently by the University of Heidelberg in Germany. Salary support for JC was provided by DFID through the TARGETS consortium at LSHTM.)

Competing Interests: The authors have declared that no competing interests exist.

Citation: Gabrysch S, Cousens S, Cox J, Campbell OMR (2011) The Influence of Distance and Level of Care on Delivery Place in Rural Zambia: A Study of Linked National Data in a Geographic Information System. PLoS Med 8(1): e1000394. doi:10.1371/journal.pmed.1000394

Source: PLoS Medicine

Jean Allott knows all too well why Sheffield Teaching Hospitals NHS Foundation Trust has been named Hospital Trust of the Year for the second time in 3 years in the Dr Foster Good Hospital Guide published on 17th November 2008.

Jean, 63 from Sheffield, had just retired from her job as a secretary at the Royal Hallamshire Hospital, when she began to experience deafness . After seeing her GP and then being referred to specialists at the Royal Hallamshire Hospital she was told the devastating news that she had a tumour the size of a small apple in the middle part of her ear.

Jean was told she only had six months to live unless she underwent extensive surgery which involved intricate skull surgery. The 20 hour operation involved six surgeons supported by a large team of anaesthetic, nursing and other healthcare staff. The operation was a success and Jean has also had amazing reconstructive surgery to rebuild her face and ear.

The operation was a success and thanks to the specialist teams at Sheffield Teaching Hospitals, Jean is now looking forward to seeing her four young grandchildren grow up.

Jean explains: “All of the staff at the hospitals deserve every bit of this accolade, the expertise, kindness and care I received was second to none.” Even now when I visit the hospital, the staff give me a big hug and bend over backwards to help me. My surgery was very specialised but I saw the same compassion and level of professionalism shown to patients simply coming to clinic for check ups. From the receptionists, to the surgeons, nurses and cleaners, the staff at Sheffield Hospitals are very special.”

Andrew Cash, the Trust’s Chief Executive of Sheffield Teaching Hospitals NHS Trust said:

I am delighted that everyone’s hard work and dedication at Sheffield Teaching Hospitals has been recognised by being named the top performing Hospital Trust in the UK. It is particularly pleasing because the title of ‘Hospital Trust of the Year’ is independently assessed and only awarded to an organisation which demonstrates excellence in the things which really matter to patients including safety, quality of care, waiting times, cleanliness of the hospitals, prevention of hospital acquired infections such as MRSA and how responsive a trust is to its patients. It is the icing on the cake for us, as it comes just a few weeks after receiving a ‘double excellent’ rating for the quality of our services and financial management in the Healthcare Commission’s Annual Performance Ratings for the second year running. However, healthcare is a joint effort across a number of organisations and so this award is also testament to the excellent staff who work for the other health and social care partners across this region.

A copy of the criteria used to assess the Trust of the Year and the Dr Foster Hospital Guide can be downloaded below:

- Trust of the Year criteria (pdf)
- Dr Foster Hospital Guide 2008 (pdf)

For more information about the Dr Foster Good Hospital Guide visit: dr fosterhealth

Sheffield Teaching Hospitals NHS Foundation Trust

A new report on the NHS Deep Clean highlights partnership work undertaken at the Norfolk and Norwich University Hospitals NHS Foundation Trust as best practice for hospitals nationally.

The deep clean process undertaken at the Norfolk and Norwich University Hospital was highlighted in the Department of Health’s ” From Deep Clean to Keep Clean, Learning from the Deep Clean Programme” report.

The hospital’s senior nurses set up a project board that brought Serco contractors and NHS staff together to tackle the Deep Clean programme together. The hospital’s cleanliness was rated by the National Patient Safety Agency as Excellent for the third year running.

Infection rates are also falling. Clostridium difficile rates at the Norfolk and Norwich University Hospital were among the lowest in the region last year and rates have continued to fall. Over the past six months the Trust has seen just 65 cases against a target of 100.

The rate of Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemia infection at NNUH was also halved over the past three years from 64 bacteraemia infections to 33 cases in 2007/08 and there have been only six cases over the past six months.

Director of Nursing Christine Baxter said; “The Deep Clean project group did a fantastic job of leading and delivering this programme and it was an excellent example of collaborative working with Serco. We are delighted that the Department of Health’s new report has highlighted some of the work we did as best practice nationally.”

The Trust’s staff have employed a wide range of measures to successfully tackle infection ranging from revised antibiotic prescribing policies, an MRSA patient screening programme, staff training, and regular audit, excellent standards of cleanliness, hand-washing and using single rooms to isolate patients with an infection.

Norfolk and Norwich University Hospitals NHS Foundation Trust