Treatment Pathways Research Articles

Investigating healthcare pathway management and inequalities using a novel data source: An observational study using linked, routinely collected data from a digital health system

ABSTRACT Acute coronary syndromes (ACS) are a common cause of morbidity in the UK. The mainstay of treatment is percutaneous coronary angiography (PCA) +/− percutaneous coronary intervention (PCI). In the Northwest sector of Greater Manchester and Salford, PCI labs are shared between hospitals and trusts, co-ordinated by a bespoke online administration system which routinely collects clinical and demographic data for patients requiring angiography. We are not aware of data from such systems previously being analysed and used to guide health service management. We isolated and linked this dataset for the year 2018 with other admission data to explore variations in the time spent on this treatment pathway (from admission to angiography). Unadjusted analysis shows pathway time is affected by weekday, date of admission, age and gender. Regression analysis using demographic and clinical variables shows a persisting disparity according to admission site and gender, with ethnic disparities that are challenging to explain. Although an observational study, the dataset is collected prospectively and has excellent granularity. As well as demonstrating feasibility of use in investigating equality of access and treatment, we demonstrate its utility for service development, management, and improvement. These methods are easily replicable across other clinical systems and specialties.

COVID-19 pandemic impact on gynecologic cancer treatment pathways in a Finnish tertiary center.

COVID-19 and new guidelines during the pandemic affected the gynecologic cancer treatment pathways, resulting in recorded delays and modifications in the treatment protocols. The aim of this study was to determine the impact of the COVID-19 pandemic in one of the major gynecologic cancer care centers in Finland, Tampere University Hospital. Our retrospective register study included 909 patients that were new gynecologic cancer cases (uterine, cervical, vulvar, vaginal, or ovarian) referred to the Tampere University Hospital Gynecologic Oncology Outpatient Clinic between March 17th, 2018, and March 15th, 2022. The patients were divided into two separate groups depending on their time of referral: time before COVID (March 17th, 2018, to March 15th, 2020), and during COVID (March 16th, 2020, to March 15th, 2022). These groups were compared in terms of patient characteristics, different cancer types and stages, symptoms, and treatment methods. During the COVID-19 pandemic, patients generally suffered from cancer symptoms longer (p < 0.003) and were more likely to be overweight (p = 0.035). The improved multidisciplinary team meeting gave the patients a faster route to their first intervention during COVID (p < 0.05). An insignificant shift toward nonsurgical first interventions and non-curative intent was seen during COVID, but the multidisciplinary team treatment plans were mostly implemented accordingly on both eras. No decrease was seen in the number of new gynecologic cancer cases, and the one-year overall survival remained the same in both groups. Overall, the COVID-19 pandemic did not significantly alter treatment pathways in gynecologic cancer care at Tampere University Hospital. The number of new patients and given treatments remained relatively stable. During COVID, access from referral to cancer treatment was significantly accelerated, which is likely confounded by changes to the multidisciplinary team protocol made in early 2021.

Exploring the anti-NSCLC mechanism of phillyrin targeting inhibition of theHSP90-AKT pathway.

Phillyrin (PHN), derived from the dried fruit of Forsythia suspensa (Thunb.) Vahl, is a kind of Chinese herbal medicine with the effect of clearing heat, and has been used in China for thousands of years in treating various tumors. However, the mechanism of its main components on non-small cell lung cancer (NSCLC) remains unclear. PHN is a distinct component extracted from Forsythia suspensa with promising anti-cancer activity against various tumor types. This study sought to elucidate the promising effects of PHN on NSCLC. Based on network pharmacology results, we identified potential PHN targets and pathways for NSCLC treatment. CCK-8 assay, wound healing assay, apoptosis assay, western blot, and in vivo experiments verified the inhibitory effect of PHN on NSCLC. Network pharmacology identified 160 potential PHN targets, 955 NSCLC-related targets, and 54 common targets, along with 132 pathways and 2 core genes. Biological experiments demonstrated that PHN significantly inhibited the growth and migration of A549 and LLC cells while promoting their apoptosis. Western blot analysis revealed down-regulation of AKT, HSP90AA1, and CDC37 expression, suggesting that PHN inhibits A549 and LLC cell proliferation by down-regulating the HSP90-AKT pathway. In vivo experiments confirmed that PHN significantly inhibited NSCLC growth with low toxicity. This study, using network pharmacology and biological experiments, verified the effectiveness of PHN against NSCLC through the HSP90-AKT pathway. These findings provide a foundation for further research and analysis.

Sulfamethoxazole degradation pathways in wastewater treatment: Bayesian network-based approach for a meta-analysis of scientific papers.

Given the widespread presence of micropollutants in urban water systems, it is imperative to gain a comprehensive understanding of their degradation pathways. This paper focuses on sulfamethoxazole (SMX) as a model molecule due to its extensive study, aiming to elucidate its degradation pathways in biological (BIO) and oxidative (AOP) processes. Numerous reaction pathways are outlined in scientific papers. However, a significant deficiency in current methodologies has led to the development of a novel meta-analytical approach, seeking consensus among researchers by synthesizing data from studies characterized by their heterogeneity and contradictions. As an innovative alternative, probabilistic graphical models such as Bayesian networks (BNs) could illuminate the relationships and dependencies between various transformation products, providing a holistic view of the degradation process. Based on the analysis of an extensive bibliography gathering more than 45 articles for more than 140 molecules and 177 reaction pathways, this study proposes a meta-analysis methodology based on Bayesian networks.

Estimation of two-year hospital costs of hip and knee periprosthetic joint infection treatments using activity-based costing.

Our aim was to estimate the total costs of all hospitalizations for treating periprosthetic joint infection (PJI) by main management strategy within 24 months post-diagnosis using activity-based costing. Additionally, we investigated the influence of individual PJI treatment pathways on hospital costs within the first 24 months. Using admission and procedure data from a prospective observational cohort in Australia and New Zealand, Australian Refined Diagnosis Related Groups were assigned to each admitted patient episode of care for activity-based costing estimates of 273 hip PJI patients and 377 knee PJI patients. Costs were aggregated at 24 months post-diagnosis, and are presented in Australian dollars. The mean cost per hip and knee PJI patient was $64,585 (SD $53,550). Single-stage revision mean costs were $67,029 (SD $47,116) and $80,063 (SD $42,438) for hip and knee, respectively. Two-stage revision costs were $113,226 (SD $66,724) and $122,425 (SD $60,874) for hip and knee, respectively. Debridement, antibiotics, and implant retention in hips and knees mean costs were $53,537 (SD$ 39,342) and $48,463 (SD $33,179), respectively. Suppressive antibiotic therapy without surgical management mean costs were $20,296 (SD $8,875) for hip patients and $16,481 (SD $6,712) for knee patients. Hip patients had 16 different treatment pathways and knee patients had 18 treatment pathways. Additional treatment, episodes of care, and length of stay contributed to substantially increased costs up to a maximum of $369,948. Treating PJI incurs a substantial cost burden, which is substantially influenced by management strategy. With an annual PJI incidence of 3,900, the cost burden would be in excess of $250 million to the Australian healthcare system. Treatment pathways with additional surgery, more episodes of care, and a longer length of stay substantially increase the associated hospital costs. Prospectively monitoring individual patient treatment pathways beyond initial management is important when quantifying PJI treatment cost. Our study highlights the importance of optimizing initial surgical treatment, and informs treating hospitals of the resources required to provide care for PJI patients.

Abdominal lymphatic malformations: a novel approach in management

Aim of the study:Abdominal lymphatic malformations (LM) are a challenging clinical entity. Complete excision can be impossible due to the infiltrative nature of some lesions and high rate of complications. Sclerotherapy may require multiple episodes of general anaesthesia and an inability to be definitive in terms of diagnosis and treatment. Subsequently we have adopted a newer algorithm of treatment involving a joint procedure with interventional radiology to enable an intra-operative treatment plan based on the findings. We present our early results. Method:A retrospective observational study in a single tertiary paediatric centre from January 2019 to December 2023. The details of each patient were recorded along with their treatment pathway and outcome. Results:12 children underwent treatment for abdominal LM. Under GA and laparoscopic vision, pigtail catheters were inserted into the lesion to effect maximal drainage and assessment of surgical anatomy. If resection was feasible this was undertaken through a laparotomy and if not, the drains were retained and sclerotherapy was started.Three underwent drainage with sclerotherapy without resection and 9 underwent drainage with resection. Of the 3 who underwent sclerotherapy 2 have had further treatment and remain under review at a mean follow up of 7.6 months. Of the other 9 there were no signs of recurrence of the LM at a mean follow up of 29 (range 6-56) months. Conclusion:We have found a combined procedure involving IR-guided drainage under laparoscopic vision enabling curative surgical resection to be undertaken, where feasible, with currently no significant morbidity. For those in whom this is not possible then direct intralesional sclerotherapy is the next most useful treatment modality for longer term control of symptoms. Level of evidence:II

Breast cancer: do the current policies mean anything?

Aim Breast cancer remains one of the most prevalent malignancies globally with a high mortality rate. South Africa has a number of policies in place designed to ensure that minimum delays are experienced by patients from first symptom to initial treatment. This study was initiated to determine where the longest delays occurred during the patient’s journey, from the first symptom to the first treatment. This information, combined with the existing policy, identifies shortfalls in the breast cancer diagnostic and treatment pathways that must be addressed. Methods A cross-sectional study was undertaken in the Department of Medical Oncology, University of Pretoria/Steve Biko Academic Hospital between April 2020 and August 2021, analysing six timelines from first symptom to first treatment in patients with newly diagnosed breast cancer. Data was obtained by the researchers from the patients on their first visit relating to the delays experienced from first symptom to final biopsy. Clinical information was obtained from the patients’ source records once a treatment decision had been reached and treatment started where applicable. Results The longest delays experienced were between the patients’ first visit to any medical facility to date of diagnostic biopsy. Delays due to COVID-19 were in the minority with 13/79 (16.4%) patients reporting having experienced COVID-19 related delays. Key Area 2 of the Breast Cancer Prevention and Control Policy makes provision for patients to be referred directly to a regional/tertiary/quaternary medical facility for further screening, diagnosis and treatment within 21-60 days from the first visit. In the study’s cohort, a mean of four months from first visit to diagnostic biopsy was recorded. Overall delays of longer than 12 months due to non-representative biopsies (range 1-3) were recorded in three patients. Twenty-nine patients (36.7%) presented to three medical facilities prior to diagnostic biopsy with 10/79 (12.6%) and 1/79 (1.2%) presenting to four and five institutions, respectively, before the diagnostic biopsy. Conclusions The delays patients experienced highlights the lack of knowledge about the urgency and correct referral of suspected malignancy cases. Despite the number of promulgated policies relating to fast track systems via specialist breast units, fiscal and human capital deficiencies negatively impact the attempts to diagnose and treat patients timeously and increase survival.

Exploring Barriers to Timely Diagnosis and Treatment of Tuberculosis in Selangor, Malaysia: A Qualitative Study.

Tuberculosis (TB) occurs as one of the highest in the state of Selangor, Malaysia and its causes are currently underexplored especially from patients' perspectives of the disease. This study assesses perspectives from patients in relations to determinants of delayed presentation, diagnosis, and treatment of TB. The study utilises a qualitative methodology involving focus group discussions and in-depth interviews with patients selected based on specific inclusion and exclusion criteria. The research covered components which include social demographic, sociocultural factors, health-seeking behaviors, social support and resources, previous knowledge and experience as a TB patient, and treatment pathway. Thematic analysis was performed using NVivo 12 analysis software to interpret the data. This study aims to identify key barriers and facilitators of prompt presentation and diagnosis of TB patients. Results revealed that socioeconomic status, challenges faced during TB diagnosis and treatment, knowledge of TB, patient and healthcare-related factors, and health-seeking behaviours were the main emerging themes. Improvements are required in the areas of access to healthcare facilities, minimizing cost, providing specific clinics and proximity of health facilities to facilitate a prompt response, increasing capacity to isolate infected persons, and provision of adequate treatment. It is revealed that financial constraints, inaccessibility and long distance to healthcare facilities, poor knowledge of TB, and lack of family and social support contributed to delayed TB presentation and diagnosis. Findings from this study can be utilized to develop effective, locally tailored interventions to address delayed presentation and diagnosis of TB patients in the nation.

Improving external fixator pin site care through user involvement: A quality improvement project

IntroductionExternal fixation is widely used in treating complex fractures and limb reconstruction. Pin site infections remain a significant complication, impacting on patients' physical and psychosocial wellbeing. This clinical improvement project at a University Hospital in Denmark aimed to enhance pin site care by involving patients and caregivers throughout the treatment pathway. BackgroundAt our hospital, approximately 55 trauma patients are annually treated with lower limb external fixators. Pin site care is crucial for preventing serious infections/osteomyelitis and involves collaboration between hospital and municipal caregivers. Traditional pin site care in our unit was complex and time-consuming, causing patient anxiety and frequent unplanned clinic visits. MethodsInspired by the Participatory Design research methodology, a quality improvement project was conducted in three phases: (1) identifying users’ needs, (2) developing solutions collaboratively, and (3) testing/evaluating these solutions. Iterative cycles of planning, acting, observing, and reflecting were employed, facilitating mutual learning among participants. Interviews with patients, families and healthcare professionals and field observations both at the hospital and in the municipality were conducted. Inspiration was sought from international literature. ResultsPhase 1 identified the need for improved education about infection recognition, a less painful and time-consuming dressing method, and an assessment tool for pin site infection. Phase 2 involved extensive user input to develop and implement a new dressing procedure using PolyMem™ along with an assessment tool. Phase 3 evaluated the new methods, revealing reduced patient pain, fewer clinic visits, and stable infection rates as well as less time-consuming pin site care. ConclusionThe project successfully enhanced pin site care, involving users in developing a new care process, thus improving patient satisfaction and care efficiency. Implications for future practiceIncorporating patient perspectives and collaborative methods can significantly improve clinical care pathways. Future efforts should focus on further integrating patient centered and participatory approaches in healthcare improvements.

Factors affecting patients on antiretroviral therapy lost to follow-up in Asunafo South District of Ahafo Region, Ghana: a cross-sectional study

IntroductionDespite the increased and effective programme coverage for antiretroviral therapy (ART), a considerable proportion of individuals receiving ART discontinue medication at different stages of their treatment pathway. In sub-Saharan Africa,...

Prevalence, incidence, and treatment of dyslipidemia in patients with high or very high cardiovascular risk in Germany

Background2019 ESC/EAS guidelines on management of dyslipidemia outline treatment goals of LDL-C reduction in patients with high and very high cardiovascular (CV) risk. ObjectiveTo describe the proportion, clinical characteristics, and treatment practices of adult patients with dyslipidemia and high or very high CV risk in Germany. MethodsBased on German claims data from 2010-2019, a retrospective cross-sectional study on prevalence, incidence, and treatment pathways in patients with dyslipidemia and high and very high CV risk is performed. ResultsBetween 2010 and 2019, there were 213 to 233 adult patients per 1,000 with prevalent dyslipidemia based on ICD 10 codes. Annual incidence ranged from 31.7 to 40.2 per 1,000. In 2019, 1.2% and 22.8% of the prevalent patients are classified to high or very high CV risk. Out of these patients, 61.7% and 78.5% received lipid lowering treatments (LLT). Among incidence patients, prescription rates are further apart between high-risk and very-high-risk patients, at 56.6% and 79.2%. Cross-sectional analysis showed that in 2019 statin monotherapy is the most common LLT (87.2%) administered mainly at moderate dose (59.9%). In that year, 2.7% and 8.4% of the patients received ezetimibe as monotherapy or in combination with statins. The proportion of treatment pause, or discontinuation was 56.6% over time, with subsequent re-initiation for 42.0% of patients. ConclusionsAnalysis indicates that despite recommendations, intensive treatment therapies are underutilized in clinical practice even in high and very high CV risk patients with primary hypercholesterolemia/mixed dyslipidemia, who may have benefited from LLT optimization.

Socioeconomic deprivation correlates with incomplete radiotherapy treatment in head and neck cancer.

There is a high burden of socioeconomic deprivation across Merseyside and, along with this, poorer cancer outcomes. The incidence of head and neck cancer squamous cell carcinoma (HNSCC) within this region is higher than the national average and there are often additional complexities to individual treatment pathways such as poor health literacy, lack of social support and transport options which can impact on adherence to prescribed treatments. AimThis work aims to understand the impact of deprivation on patients diagnosed with HNSCC undergoing chemoradiotherapy (CRT) or radiotherapy (RT) treatment through identifying barriers to adherence. MethodsPatients with HNSCC treated between June 2022-June 2023 were included and data collected through retrospective case note review. Approval was obtained from relevant NHS institution audit departments. Key examined variables were indices of multiple deprivation (IMD), unplanned admission rate, hospital transport use, social support network and provision of additional adhoc appointments during treatment courses. All were correlated with missed radiotherapy appointments. ResultsOut of 359 evaluable patients there were high levels of unplanned appointments with health professionals during CRT/RT (71% of those receiving CRT and 55% of those having RT). 11% (n=39) missed at least one radiotherapy appointment with the commonest reason being unplanned admission to hospital. Despite missed appointments, 25/39 patients completed treatment within prescribed window due to effective RT compensation strategies. On multivariate analysis, unplanned admission, hospital provided transport and crime deprivation quintiles (p=<0.001, p=0.007 and p=0.027 respectively) were found to significantly increase the chance of missed radiotherapy treatment appointments. ConclusionHigh levels of unplanned encounters with health care professionals are encouraging adherence to non-surgical HNSCC treatments. Formalising these adhoc appointments will provide an equitable, robust service. Undertaking hospital transport increases potential for missed treatment appointments. Gaining insight into patient experiences and investing in improved transport services are essential for maximising adherence.

Survival in Thyroid Cancer in Sweden From 1999 To 2018.

Thyroid cancer (TC) is diagnosed in several histological types which differ in their clinical characteristics and survival. We aim to describe how they influence TC survival in Sweden. Cancer data were obtained from the Swedish cancer registry between years 1999 and 2018, and these were used to analyze relative survival. Relative survival for all TC improved when analyzed in 10-year periods, and female survival improved more than male survival. Female survival advantage appeared to be present also for specific histological types, although case numbers were low for rare types. Female 5-year relative survival for TC was 100% for follicular, 95.1% for oncocytic, 93.4% for papillary, 89.7% for medullary, and 6.1% for anaplastic cancer. Among the clinical TNM classes, only T4 and M1 stages were associated with decreased survival compared to T1-3 and M0. Anaplastic cancer presented most often at high T and M1 stages, in contrast to other TC. Curiously, the diagnostic age for anaplastic M1 patients was lower than that for M0 patients. Both anaplastic and medullary cancers did not show age-dependent increases in the probability of metastases, in contrast to the main histological types. This could indicate the presence of several types of anaplastic and medullary cancers. The poor survival for anaplastic TC is an extreme contrast to the excellent survival of differentiated TC. As less than 20% of anaplastic cancer patients survived one year, urgent diagnosis and initiation of treatment are important. Facilitated treatment pathways have been instituted in Denmark resulting in improved survival. Anaplastic cancer should be a target of a major research focus.

Baseline characteristics and predictors for early implantation of vagus nerve stimulation therapy in people with drug-resistant epilepsy: Observations from an international prospective outcomes registry (CORE-VNS).

Vagus nerve stimulation (VNS) Therapy is routinely indicated for people with drug-resistant epilepsy (DRE). We analyzed the baseline characteristics of individuals receiving the recently released VNS models and identified factors associated with early or late implantation. The Comprehensive Outcomes Registry of subjects with Epilepsy (CORE-VNS), a prospective observational study evaluating the clinical and psychosocial outcomes of VNS Therapy®, is following participants for up to 60 months after VNS implantation. In this analysis, we used Cox proportional hazards model to identify baseline characteristics associated with the time from diagnosis to first implantation. Of the 819 enrolled, 792 (96.7%) participants implanted with a VNS device were evaluated. 529 (64.6%) underwent the first implantation and 263 (32.1%) a re-implantation. Participants' median age at first implant was 24 years; 492 (62.1%) were ≥18 years old and 166 (20.3%) were < 12 years old. The average number of failed ASMs prior to VNS implantation was 7.1, and 145 (17.7%) had undergone previous epilepsy-related surgery. Epilepsy was classified as focal in 47.7% of participants, generalized in 16.1% and combined focal and generalized in 34.2%. Many of the participants (40.9%) had epilepsy of unknown etiology. The median time from diagnosis to first implantation was 10.33 years and was significantly shorter in participants with combined focal and generalized epilepsy compared to those with focal epilepsy alone, and in participants with genetic and immune epilepsy compared to those with unknown etiologies. In people with DRE, VNS Therapy is provided after multiple failures of ASMs and after failure of epilepsy surgery in one in six individuals. Time from diagnosis to first implantation is associated with epilepsy type and etiology, likely reflecting variable treatment pathways. Clearer guidelines on when and how non-drug therapies should be deployed in people with DRE related to different epilepsy factors are needed. Neuromodulation can be a very helpful treatment in people who have seizures that do not respond to medications. The most widely utilized neuromodulation therapy is vagus nerve stimulation (VNS). We present data from a large, global study to show that people use an average of seven anti-seizure medications before attempting VNS Therapy and that it takes about 10 years for people to get their first VNS implant. We advocate for clearer treatment guidelines on how and when to consider VNS Therapy in people with seizures that are resistant to medication.

Alitretinoin versus phototherapy as the first-line treatment in adults with severe chronic hand eczema: the ALPHA RCT.

Hand eczema is common and a cause of morbidity and occupational disability. When education, irritant/contact allergen avoidance, moisturisation and topical corticosteroids are insufficient to control chronic hand eczema, ultraviolet therapy or systemic immune-modifying drugs are used. There is no treatment pathway generally accepted by UK dermatologists. Compare alitretinoin and ultraviolet therapy as first-line therapy in terms of disease activity at 12 weeks post planned start of treatment. Prospective, multicentre, open-label, two-arm parallel group, adaptive randomised controlled trial with one planned interim analysis, and an economic evaluation. UK secondary care dermatology outpatient clinics. Patients with severe chronic hand eczema unresponsive to at least 4 weeks of treatment with potent topical corticosteroids. Natural logarithm of the Hand Eczema Severity Index + 1, 12 weeks post planned start of treatment. Participants randomised 1:1 by minimisation to alitretinoin or ultraviolet therapy for 12 to 24 weeks. Blinded primary end-point assessor. Intention-to-treat population: 441 (100.0%) participants; 220 (49.9%) alitretinoin and 221 (50.1%) ultraviolet therapy. At least one dose was received by 212 (96.4%) alitretinoin and 196 (88.7%) ultraviolet therapy participants. The unadjusted median (interquartile range) relative change in hand eczema severity index at 12 weeks was 30% (10-70%) of that at baseline for alitretinoin compared with 50% (20-100%) for ultraviolet therapy. There was a statistically significant benefit of alitretinoin compared with ultraviolet therapy at 12 weeks, with an estimated fold change or relative difference (95% confidence interval) = 0.66 (0.52 to 0.82), p = 0.0003 at 12 weeks. There was no evidence of a difference at 24 or 52 weeks, with the estimated fold change (95% confidence interval) equal to 0.92 (0.798 to 1.08) and 1.27 (0.97 to 1.67), respectively. Fifty-nine per cent allocated to alitretinoin and 61% allocated to ultraviolet therapy achieved a clear/almost clear assessment during the trial period. Differential treatment compliance observed: 145 (65.9%) alitretinoin and 53 (24.0%) ultraviolet therapy participants confirmed compliance (≥80% received, no treatment breaks > 7 days during first 12 weeks). High levels of missing data were observed. One hundred and thirty-five reportable adverse events across 79 participants, 55 (25.0%) alitretinoin and 24 (10.9%) ultraviolet therapy. Four serious adverse events (two alitretinoin, two ultraviolet therapy). Four pregnancies reported (three alitretinoin, one ultraviolet therapy). No new safety signals were detected. As a first-line therapy, alitretinoin showed more rapid improvement and superiority to ultraviolet therapy at week 12. This difference was not observed at later time points. Alitretinoin is cost-effective at weeks 12 and 52. Ultraviolet therapy is cost-effective after 10 years, with a high degree of uncertainty. Hand eczema severity index may be a useful primary outcome measure for hand eczema trials; ALPHA results will inform future trials. Treatment compliance was poor for ultraviolet therapy. Regular twice weekly treatment was not received by most patients. Assessment of long-term effects of randomised treatments was complicated by use of second-line treatments post treatment phase. Further analysis of substudies and pilot data will provide valuable information for future studies. A clear need for better therapeutic approaches for severe chronic hand eczema remains. Future studies will need to further address long-term benefits of treatments given. This trial is registered as ISRCTN80206075. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/186/01) and is published in full in Health Technology Assessment; Vol. 28, No. 59. See the NIHR Funding and Awards website for further award information.

Beyond diagnosis: using a futurist approach to improve access to radiation oncology services in South Africa

Aim Radiation oncology is an integral aspect of comprehensive cancer treatment, with approximately 50% of patients requiring curative or palliative radiotherapy intervention. In the South African public sector, radiation oncology services are constrained by various factors including service coverage, equipment and staff shortages, causing consequent delays in access to care. The National Cancer Strategic Framework for South Africa (NCSF) (2017-2022) offers strategic direction for cancer services in the country. Methods Futurist causal layered analysis (CLA) provides a comprehensive approach to exploring the multifaceted factors that influence access to radiation oncology services. Using the established layers of CLA, namely, the litany, systemic, worldview and mythical layers, the NCSF, relevant literature, and expert perspectives, were used to explore the multiple levels of influence related to radiation oncology services in South Africa. Findings Considering litany, review of process flows and radiation oncology care models could offer strategic pathways for reducing waiting times and improving access to care. From the systemic layer analysis, health system strengthening should include improving clinical governance and access to available services within both the public and private sectors. This could simultaneously address the worldview of an unconstitutional lack of access to radiation oncology care within the public health sector. The final level considered myths related to radiation oncology in South Africa, including its perceived efficacy only in advanced cancer stages, and highlighted the importance of a business case for radiation oncology services to support enhanced planning and outcomes. Conclusions CLA methodology offers new insights into the challenges and opportunities facing radiation oncology services in South Africa. By comprehensively addressing the complex causal layers impacting radiation oncology services, policymakers and stakeholders can make more informed decisions to improve access to radiation oncology care in the country. The study recommends that the entire cascade of cancer care, including treatment pathways and multi-stakeholder perspectives, should be reviewed. Internal and external factors that delay the initiation of radiotherapy should be mapped and mitigated.

Causes, Diagnostic Testing, and Treatments Related to Clinical Deterioration Events Among High-Risk Ward Patients.

Timely intervention for clinically deteriorating ward patients requires that care teams accurately diagnose and treat their underlying medical conditions. However, the most common diagnoses leading to deterioration and the relevant therapies provided are poorly characterized. We aimed to determine the diagnoses responsible for clinical deterioration, the relevant diagnostic tests ordered, and the treatments administered among high-risk ward patients using manual chart review. This was a multicenter retrospective observational study in inpatient medical-surgical wards at four health systems from 2006 to 2020. Randomly selected patients (1000 from each health system) with clinical deterioration, defined by reaching the 95th percentile of a validated early warning score, electronic Cardiac Arrest Risk Triage, were included. Clinical deterioration was confirmed by a trained reviewer or marked as a false alarm if no deterioration occurred for each patient. For true deterioration events, the condition causing deterioration, relevant diagnostic tests ordered, and treatments provided were collected. Of the 4000 included patients, 2484 (62%) had clinical deterioration confirmed by chart review. Sepsis was the most common cause of deterioration (41%; n = 1021), followed by arrhythmia (19%; n = 473), while liver failure had the highest in-hospital mortality (41%). The most common diagnostic tests ordered were complete blood counts (47% of events), followed by chest radiographs (42%) and cultures (40%), while the most common medication orders were antimicrobials (46%), followed by fluid boluses (34%) and antiarrhythmics (19%). We found that sepsis was the most common cause of deterioration, while liver failure had the highest mortality. Complete blood counts and chest radiographs were the most common diagnostic tests ordered, and antimicrobials and fluid boluses were the most common medication interventions. These results provide important insights for clinical decision-making at the bedside, training of rapid response teams, and the development of institutional treatment pathways for clinical deterioration.

The Evolving Role of Genomics in Colorectal Cancer

Approximately 75% of colorectal cancers (CRCs) harbour an identifiable driver mutation, 5% of these being heritable. These drivers have recognised implications for prognosis and therapy selection. In addition, potential germline mutations require investigations to inform testing of relatives, as well as surveillance for other malignancies. With increasing numbers of targeted drugs being approved, judicious testing is required to ensure sufficient tumour is available for testing and at the right point in the cancer pathway. Liquid biopsy with circulating tumour DNA (ctDNA) in the blood presents an exciting adjunct to tumour tissue testing for molecular drivers, as well as escalation and de-escalation of therapy. We review the most frequent molecular alterations in CRC, how genomic testing should be integrated into the treatment pathway for CRC, and sources of further education.

Using Oncology Treatment Pathway Data to Evaluate Serious Illness Communication, Care Utilization, and End-of-Life Care for Patients With Cancer.

Oncology treatment pathways provide decision support and encourage guideline adherence. Pathway data combined with electronic health record (EHR) data can identify patient populations with poor prognoses, low serious illness conversation (SIC) rates, and high acute care utilization that may benefit from targeted interventions. We conducted a retrospective cohort analysis among adults with cancer treated at seven affiliated sites of the Dana-Farber Cancer Institute (DFCI) who had navigations within 21 treatment pathways between July 29, 2019, and March 8, 2023. DFCI clinicians previously identified pathway nodes with an estimated survival less than 1 year, termed poor prognosis (PP) nodes. We combined pathway data with EHR data to calculate the median overall survival (OS) and proportion of patients with SICs, acute care utilization (hospitalizations and emergency department visits), and outpatient palliative care 6 months after treatment node navigation for all, PP, and nonpoor prognosis (nPP) nodes. SICs were identified using the EHR advanced care planning (ACP) tab. There were 15,261 navigations for 10,203 patients (median age 66 years, 55% female, 85% White). The median OS was 13.8 months for all nodes, 7.8 months for PP nodes, and 21.0 months for nPP nodes. The ACP section of the EHR rate 6 months after navigation was 19.6% for PP nodes versus 11.0% for nPP nodes. There was substantial intragroup variability in OS and SIC rates among all nodes. SICs were recorded in the ACP tab for only 34.3% of decedents. Patients who navigated to PP nodes had higher levels of acute care utilization and palliative care encounters. Treatment pathway data enabled identification of patient populations with poor prognoses, low SIC rates, and high acute care utilization.

The Social Reality of Meaning Making: The Dichotomy in the Illness Narratives of Women With Breast Cancer and Biomedical Practitioners in Nigeria.

Despite the increasing burden of breast cancer in the developing world, there is a misunderstanding of the complex and multifaceted relationship between culture and cancer, particularly breast cancer. Hence, a dichotomy of illness narratives exists due to differential meaning making concerning breast cancer. While clinicians always recommend biomedical treatment, women with breast cancer often seek alternative treatment pathways. To explore the experiences of women with breast cancer and clinicians in Nigeria on the dichotomy in the illness narratives. This qualitative study used in-depth interviews and focus group discussion to explore the experiences of 22 women with breast cancer and 7 clinicians in Nigeria on the dichotomy in the illness narratives using grounded theory method analysis. This study revealed that many women living with breast cancer (WLBC) hold health beliefs that are contradictory to the biomedical norm. They mostly sought treatment based on the perceived aetiology of breast cancer. The treatment pathway follows faith and traditional healing as alternatives or sometimes in combination with biomedicine. WLBC reported a constant fear of biomedical treatment, perceived to be harmful to women's sexuality, fertility and body image. Hence, after perceived treatment failure from alternative care, biomedical care becomes the last resort, usually at an advanced stage of breast cancer, often responsible for poor prognosis. There is a dichotomy of illness construction between sufferers and health practitioners. To guide women with breast cancer on the path of care, modern care practitioners should consider some cultural norms and practices without compromising professional ethos.