Patient Travel Burden Research Articles

Sharing Post-AML Consolidation Supportive Therapy with Local Centers Reduces Patient Travel Burden without Compromising Safety and Efficacy of Care

AML (acute myeloid leukemia) is frequently treated with intensive induction and consolidation chemotherapy that often requires prolonged admissions to hospital. Our group and others demonstrated that consolidation chemotherapy for AML can be safely and effectively administered to selected patients on an ambulatory basis. However, this ambulatory care is centralized in quaternary centers, requiring some patients to travel long distances to these specialized centres. Recently, we developed a shared care model where patients receive their consolidation chemotherapy for AML at the specialized quaternary care center, but receive post-consolidation supportive care including blood checks, transfusions, and treatment for febrile neutropenia at their local hospitals. Here, we reviewed the impact of our new model of care with a focus on savings in travel time and distance.Between 2009-2013, 73 patients with AML (n=61,) or APL (n=12) received post-consolidation care after CR1 at 14 local centers in the province of Ontario. These centers were regional cancer centers staffed by oncologists and/or hematologists experienced in the management of cytopenias and febrile neutropenia. However, these centers did not provide induction or consolidation chemotherapy for AML. Patients were seen at least weekly as out-patients at these hospitals while recovering from their consolidation chemotherapy. These centers were located a median of 70 km (range: 36-190) from the quaternary centre (The Princess Margaret Cancer Centre in Toronto, Canada). The 73 patients received 137 cycles of intensive consolidation where the post-consolidation care was provided by their local centre. The local centers treated a median of 2 patients (range of 1-19 patients) during the time frame evaluated.Patients receiving shared care had a median age of 57 years (range: 21.7-78.6) and 40 (54.8%) were male. 7 (9.6%) had favourable, 42 (57.5%) had intermediate, 6 (8.2%) had poor and 18 (24.7%) had indeterminate cytogenetic profiles.Google Maps (www.google.ca/maps) was used to calculate the distance travelled and estimated travel time between the patient's home and the quaternary centre or their local centre. Use of toll roads was permitted to achieve the fastest and shortest distance. Patients in the shared care model travelled a mean distance of 99.5 km ± 57.8 (median: 87.8 range: 28.4-266 km) each way to the quaternary care centre versus 26.3 km ± 33.6 (median: 14.5 range: 0.55-211 km) each way to their local treatment centre (p <0.001 for difference in means by t-test). The estimated mean time to travel from their home to the quaternary center was 71.6 ± 38 minutes (median: 62 range: 29-170) and the estimated time to travel to their local center was 23.3 ± 21.9 minutes (median: 18 range: 2-137) (p <0.001 for difference in means by t-test). Thus, by receiving post-consolidation care locally, patients saved a mean round trip travel distance of 146.5 km ± 99.6 and 96.7 min ± 63.4 of round trip travel time per visit compared to travelling to the quaternary care centre.To assess the safety and efficacy of the shared care model, we compared the survival of the patients who received shared care to that of the other 344 patients with AML (n=297) or APL (n=47) who received consolidation chemotherapy in CR1 during the same time frame and remained at the quaternary care centre for all of their post-consolidation care. Gender, age and cytogenetic risk did not significantly differ between the shared care group and the group of patients receiving all of their care at the quaternary center (p>0.05). There was no significant difference in overall survival between the 2 groups (p value of log-rank test >0.05). 30, 60, and 90 day survival from start of consolidation chemotherapy was 98.6%, 97.2%, and 95.9% for the patients receiving shared care and 98.8%, 97.1%, and 95.3% for patients receiving all of their care at the quaternary center. Multivariate Cox proportional hazards model revealed no significant increase in hazard of death for the Shared Care patients compared to control when controlling for age, gender, AML vs. APL and cytogenetic prognosis (p value >0.05).Thus, a collaborative care delivery model utilizing partnerships with regional centres for post-consolidation care in AML reduces patient travel burden while maintaining safety and efficacy. DisclosuresNo relevant conflicts of interest to declare.

Home-based self-delivered mirror therapy for phantom pain: A pilot study

To test the feasibility and preliminary efficacy of self-delivered home-based mirror therapy for phantom pain. Uncontrolled prospective treatment outcome pilot study. Forty community-dwelling adults with unilateral amputation and phantom pain > 3 on a 0-10 numeric rating scale enrolled either during a one-time study visit (n = 30) or remotely (n = 10). Participants received an explanation of mirror therapy and were asked to self-treat for 25 min daily. Participants completed and posted back sets of outcomes questionnaires at months 1 and 2 post-treatment. Main outcome was average phantom pain intensity at post-treatment. A significant reduction in average phantom pain intensity was found at month 1 (n = 31, p = 0.0002) and at month 2 (n = 26, p = 0.002). The overall median percentage reduction at month 2 was 15.4%. Subjects with high education (> 16 years) compared with low education (< 16 years) (37.5% vs 4.1%) had greater reduction in pain intensity (p = 0.01). These findings support the feasibility and efficacy of home-based self-delivered mirror therapy; this low-cost treatment may defray medical costs, therapy visits, and the patient travel burden for people with motivation and a high level of education. More research is needed to determine methods of cost-effective support for people with lower levels of education.

Mobile Direct Observation Treatment for Tuberculosis Patients: A Technical Feasibility Pilot Using Mobile Phones in Nairobi, Kenya

Growth in mobile phone penetration has created new opportunities to reach and improve care to underserved, at-risk populations including those with tuberculosis (TB) or HIV/AIDS. This paper summarizes a proof-of-concept pilot designed to provide remote Mobile Direct Observation of Treatment (MDOT) for TB patients. The MDOT model combines Clinic with Community DOT through the use of mobile phone video capture and transmission, alleviating the travel burden for patients and health professionals. Three healthcare professionals along with 13 patients and their treatment supporters were recruited from the Mbagathi District Hospital in Nairobi, Kenya. Treatment supporters were asked to take daily videos of the patient swallowing their medications. Patients submitted the videos for review by the health professionals and were asked to view motivational and educational TB text (SMS) and video health messages. Surveys were conducted at intake, 15 days, and 30 days. Data were collected in 2008 and analyzed in 2009. All three health professionals and 11 patients completed the trial. All agreed that MDOT was a viable option, and eight patients preferred MDOT to clinic DOT or DOT through visiting Community Health Workers. MDOT is technically feasible. Both patients and health professionals appear empowered by the ability to communicate with each other and appear receptive to remote MDOT and health messaging over mobile. Further research should be conducted to evaluate whether MDOT (1) improves medication adherence, (2) is cost effective, and (3) can be used to improve treatment compliance for other diseases such as AIDS.

Centralization of Cancer Surgery: Implications for Patient Access to Optimal Care

The volume-outcomes relationship has led many to advocate centralization of cancer procedures at high volume hospitals (HVH). We hypothesized that in response cancer surgery has become increasingly centralized and that this centralization has resulted in increased travel burden for patients. Using 1996 to 2006 discharge data from NY, NJ, PA, all patients > or = 18 years old treated with extirpative surgery for colorectal, esophageal, or pancreatic cancer were examined. Patients and hospitals were geocoded. Annual hospital procedure volume for each tumor site was examined, and multiple quantile and logistic regressions were used to compare changes in centralization and distance traveled. Five thousand two hundred seventy-three esophageal, 13,472 pancreatic, 202,879 colon, and 51,262 rectal procedures were included. A shift to HVH occurred to varying degrees for all tumor types. The odds of surgery at a low volume hospital decreased for esophagus, pancreas and colon: per year odds ratios (ORs) were 0.87 (95% CI, 0.85 to 0.90), 0.85 (95% CI, 0.84 to 0.87), and 0.97 (95% CI, 0.97 to 0.98). Median travel distance increased for all sites: esophagus 72%, pancreas 40%, colon 17%, and rectum 28% (P < .0001). Travel distance was proportional to procedure volume (P < .0001). The majority of the increase in distance was attributable to centralization. There has been extensive centralization of complex cancer surgery over the past decade. While this process should result in population-level improvements in cancer outcomes, centralization is increasing patient travel. For some subsets of the population, increasing travel requirements may pose a significant barrier to access to quality cancer care.