Outpatient-based bone marrow transplantation for hematologic malignancies: cost saving or cost shifting?

PURPOSE: To determine whether a shift in care from an inpatient-based to an outpatient-based bone marrow transplantation (BMT) program decreased charges to payers without increasing clinical complications or out-of-pocket costs to patients. PATIENTS AND METHODS: This nonrandomized prospective cohort study compared clinical and economic outcomes for 132 consecutive BMT patients with hematologic malignancies who received either inpatient- or outpatient-based BMT care. RESULTS: Seventeen of 132 BMT patients underwent outpatient-based BMT. Compared with the inpatient-based group, the outpatient-based group had a markedly lower mean number of inpatient hospital days (22 v 47; P <.001) and decreased mean inpatient facility charges ($61,059 less per patient; P <.0001) but had higher mean outpatient facility charges ($49,732 higher; P <. 0001). Total professional fees were similar for the groups. The mean total charge to payers was only 7% less ($12,652; P =.21) for outpatient-based BMT than for inpatient-based BMT, but total charge was 34% less for outpatient compared with inpatient BMT ($54,240; P = 0.056) in a subset of patients who had a standard rather than high risk of treatment failure. There was no significant difference between groups in out-of-pocket costs for transportation, lodging, meals, home nursing, household assistance, child care, medication expenses, or unreimbursed medical bills. There also was no significant difference between groups in reported income lost, involuntary unemployment, or months of disability. The two groups had similar rates of major complications, including death, significant acute graft-versus-host disease, and veno-occlusive disease of the liver. CONCLUSION: Increased use of outpatient-based BMT should produce substantial cost savings for payers without adverse effects on patients for those patients who do not have a high risk of treatment failure.

Fatigue: definitions, mechanisms, and paradigms for study.

Interferon-alpha (IFN-alpha) therapy is frequently associated with significant fatigue, which is often the dominant dose-limiting side effect. The fatigue associated with IFN-alpha therapy is usually dose related, worsens with continued therapy, and is associated with significant depression. Although the direct cause of IFN-alpha-induced fatigue is unknown, it is possible that neuromuscular fatigue, similar to that observed in patients with postpolio syndrome, is one component of this syndrome. The induction of proinflammatory cytokines observed in patients treated with IFN-alpha is consistent with a possible mechanism of neuromuscular pathology that could manifest as fatigue. Further research using established techniques for the study of neuromuscular fatigue is needed to test this hypothesis. Understanding the etiology of IFN-alpha-induced fatigue is the first step toward developing effective therapeutic interventions. Nonpharmacologic interventions for fatigue have begun to be seriously evaluated in cancer patients and patients receiving IFN-alpha therapy. Pharmacologic interventions for neuromuscular fatigue also are being investigated.

NCCN Practice Guidelines for Cancer-Related Fatigue.

These guidelines propose a treatment algorithm in which patients are evaluated regularly for fatigue, using a brief screening instrument, and are treated as indicated by their fatigue level. The algorithm's goal is to identify and treat all patients with fatigue that causes distress or interferes with daily activities or functioning. Management of fatigue begins with primary oncology team members who perform the initial screening and either provide basic education and counseling or expand the initial screening to a more focused evaluation for moderate or higher levels of fatigue. At this point the patient is assessed for the five primary factors known to be associated with fatigue: pain, emotional distress, sleep disturbance, anemia, and hypothyroidism. If any of these conditions are present, it should be treated according to practice guidelines, and the patient's fatigue should be reevaluated regularly. If none of the primary factors is present or the fatigue is unresolved, a more comprehensive assessment is indicated--with referral to other care providers as appropriate. The comprehensive assessment should include a thorough review of systems, review of medications, assessment of comorbidities, nutritional/metabolic evaluation, and assessment of activity level. Management of fatigue is cause-specific when conditions known to cause fatigue can be identified and treated. When specific causes, such as infection, fluid and electrolyte imbalances, or cardiac dysfunction, cannot be identified and corrected, nonpharmacologic and pharmacologic treatment of the fatigue should be considered. Nonpharmacologic interventions may include a moderate exercise program to improve functional capacity and activity tolerance, restorative therapies to decrease cognitive alterations and improve mood state, and nutritional and sleep interventions for patients with disturbances in eating or sleeping. Pharmacologic therapy may include drugs such as antidepressants for depression or erythropoietin for anemia. A few clinical reports of the use of corticosteroids and psychostimulants suggest the need for further research on these agents as a potential treatment modalities in managing fatigue. Basic to these interventions, the effective management of cancer-related fatigue involves an informed and supportive oncology care team that assesses patients' fatigue levels regularly and systematically and incorporates education and counseling regarding strategies for coping with fatigue (Johnson, 1999), as well as using institutional fatigue management experts for referral of patients with unresolved fatigue.

A nursing rehabilitation program for women with breast cancer receiving adjuvant chemotherapy.

PURPOSE/OBJECTIVES: To examine the effects of a comprehensive rehabilitation program on facilitating physical and psychosocial adaptation of women with breast cancer who are receiving adjuvant chemotherapy. DESIGN: Experimental. SETTING: Breast evaluation clinics of two New England medical centers with comprehensive cancer treatment programs. SAMPLE: 14 women (mean age = 44 years) receiving adjuvant chemotherapy for breast cancer (86% stage II) following surgical treatment. METHODS: Subjects were assigned randomly to the experimental group or the usual care group. Experimental group members began a structured exercise program of walking and attended support group meetings. All subjects were tested before beginning chemotherapy, during the course of chemotherapy, and one month following chemotherapy completion. MAIN RESEARCH VARIABLES: Performance status, physical functioning, psychosocial adjustment, self-concept and body image, and 12 symptoms (e.g., fatigue, nausea, anxiety). FINDINGS: Measures of physical performance, psychosocial adjustment, and symptom intensity revealed improved adaptation in subjects who completed the walking/support group program. CONCLUSIONS: Physical and psychosocial benefits from a modest walking exercise program and a support group are possible for patients receiving adjuvant chemotherapy. IMPLICATIONS FOR NURSING PRACTICE: Although more detailed research is necessary to answer some of the questions raised by this study, implementing the walking program and forming a support group are achievable in an outpatient setting.

Effects of exercise on fatigue, physical functioning, and emotional distress during radiation therapy for breast cancer.

PURPOSES/OBJECTIVES: To test the hypothesis that women participating in a walking exercise program during radiation therapy treatment for breast cancer would demonstrate more adaptive responses as evidenced by higher levels of physical functioning and lower levels of symptom intensity than women who did not participate. DESIGN: Experimental, two-group pretest, post-test. SETTING: Two university teaching hospital outpatient radiation therapy departments. SAMPLE: 46 women beginning a six-week program of radiation therapy for early stage breast cancer. METHODS: Following random assignment, subjects in the exercise group maintained an individualized, self-paced, home-based walking exercise program throughout treatment. The control group received usual care. Dependent variables were measured prior to and at the end of radiation therapy. In addition, symptoms were assessed at the end of three weeks of treatment. MAIN RESEARCH VARIABLES: Participation in the walking exercise program, physical functioning fatigue, emotional distress, and difficulty sleeping. FINDINGS: Hypothesis testing by multivariate analysis of covariance, with pretest scores as covariates, indicated significant differences between groups on outcome measures (p < 0.001). The exercise group scored significantly higher than the usual care group on physical functioning (p = 0.003) and symptom intensity, particularly fatigue, anxiety, and difficulty sleeping. Fatigue was the most frequent and intense subjective symptom reported. CONCLUSIONS: A self-paced, home-based walking exercise program can help manage symptoms and improve physical functioning during radiation therapy. IMPLICATIONS FOR NURSING PRACTICE: Nurse-prescribed and -monitored exercise is an effective, convenient, and low-cost self-care activity that reduces symptoms and facilitates adaptation to breast cancer diagnosis and treatment.

Establishing mechanisms to conduct multi-institutional research--fatigue in patients with cancer: an exercise intervention.

PURPOSES/OBJECTIVES: To describe the process of establishing a multi-institutional interdisciplinary team of oncology researchers and conducting a pilot study of an exercise intervention for fatigue. DATA SOURCES: Project meeting minutes and records, research team members' logs, subjects' research records, the research study proposal, and team members' individual and collective shared experiences. DATA SYNTHESIS: Site investigators established research teams at five academic medical centers. Fifty subjects were enrolled in the study and tested during their cancer treatment. Study methods, including instrumentation, were evaluated carefully and revised. CONCLUSIONS: The multi-institutional network of researchers is an effective and efficient model for testing an intervention to manage fatigue during cancer treatment. IMPLICATIONS FOR NURSING PRACTICE: Exercise is a feasible and potentially beneficial intervention to combat distressing cancer treatment-related fatigue. A pilot study is essential to determine the best methods for conducting a clinical trial and to develop the teams of researchers necessary for such a project.

Breast cancer and fatigue: issues for the workplace.

1. Women with breast cancer are at high risk for fatigue as a side effect of treatment with surgery, radiation, and chemotherapy. The risk is compounded by the multiple roles of women who return to work during treatment. 2. The fatigue experience includes a physical component of decreased functional status, an affective component of emotional distress, and a cognitive component of difficulty concentrating. These characteristics of fatigue may present significant challenges for employees. 3. The Family Medical Leave Act provides 12 weeks of unpaid leave to receive medical treatment and/or recover from treatment for breast cancer. 4. The nurse in the workplace can assess and monitor the effects of fatigue and teach employees to manage fatigue through energy conservation, effective use of energy, and health promotion activities to restore energy levels.

Body image in women treated for breast cancer.

Body image, as a component of self-concept, was compared in four groups of women (N = 257) who received the most common types of treatment for breast cancer: mastectomy, mastectomy with delayed reconstruction, mastectomy with immediate reconstruction, and conservative surgery. Data were collected by mailed questionnaires using self-report instruments. Comparison of groups using analysis of covariance with age as a covariate indicated that mean body image in the conservative surgery group was significantly more positive than in either the mastectomy group or in the mastectomy with immediate reconstruction group. No differences in self-concept were evident among the four groups.

Evaluating a model of fatigue in children with cancer.

This evaluation of a program of research on fatigue in children with cancer is a critique of the model developed as an outcome of the research. Emphasis is placed on the research methods as well as on the contribution to knowledge development related to pediatric cancer-related fatigue.

Fatigue management: evidence and guidelines for practice.

Fatigue has been described as the most common, most debilitating side effect of cancer treatment and is frequently reported as a long-term complication of treatment as well. Despite the prevalence of fatigue and its profoundly negative effect on patients' quality of life, little is known about the specific mechanisms that underlie fatigue in cancer patients or how to prevent it and treat it effectively. The National Comprehensive Cancer Network (NCCN) Fatigue Practice Guidelines Panel has reviewed the available evidence and the consensus of practitioners regarding the management of fatigue and has developed clinical practice guidelines. These guidelines are presented in this article, with a discussion of levels of evidence for interventions recommended by the guidelines. Gaps exist in our knowledge of fatigue and further research is needed to support the NCCN Practice Guidelines for fatigue; however, there is a developing body of knowledge and consensus of clinicians regarding the management of fatigue in cancer patients. Additional research directed toward the knowledge gaps would strengthen the Practice Guidelines.

Caregiver responses and needs. An ambulatory bone marrow transplant model.

PURPOSE: This longitudinal, descriptive outcomes study was conducted to compare the emotional responses and needs of the caregivers of patients who undergo bone marrow transplantation (BMT) for hematologic malignancies, as observed in an inpatient/outpatient (IPOP) setting with those in an inpatient setting. DESCRIPTION OF STUDY: A convenience sample of 43 caregivers for patients undergoing either autologous or allogeneic BMT was selected from both the inpatient unit (n = 26) and the IPOP ambulatory setting (n = 17). Emotional responses were measured by the Profile of Mood States. The importance and satisfaction of informational, patient-care, and psychological needs were assessed with the Caregiver Needs Survey, a modified version of the Home Cancer Caregiver Needs Survey. Data were collected at six points across the BMT trajectory, from before the procedure to 12 months after. Descriptive statistics were used to report sample characteristics, emotional responses, and needs. Nonparametric statistics were used to compare the IPOP and inpatient caregiver groups, and to identify relationships between emotional responses and needs within groups. RESULTS: IPOP caregivers were found to have significantly less mood disturbance at points before discharge. Both groups showed a decrease in mood disturbance 6 and 12 months after BMT. IPOP caregivers had higher levels of satisfaction of their informational and psychological needs at day 21. Significant correlations between total mood disturbance and satisfaction of informational, psychological, and patient-care needs were found for inpatient caregivers across treatment time points. CLINICAL IMPLICATIONS: These findings support the IPOP model of care as being less emotionally distressing for and better meeting the needs of family caregivers. Specific implications for practice include the importance of caregiver education in the area of patient-care information and of assessment and intervention to meet caregiver psychological needs. Continued evaluation of the impact of changes in care delivery on family caregivers is essential for the provision of comprehensive cancer care.

Challenges to behavioral research in oncology.

PURPOSE: The difficulties encountered by investigators in conducting behavioral research with oncology patients have received little attention in the literature. This article provides a practical guide to problems that might be anticipated in the planning and conduct of behavioral research. OVERVIEW: Problems include subject accrual and retention, development of a multidisciplinary research team, control of confounding variables, psychosocial instrumentation issues, and acceptance of the need for behavioral research. Methodological and feasibility issues are examined. Strategies for addressing the issues are presented. CLINICAL IMPLICATIONS: Successful behavioral research in oncology requires firm grounding in clinical practice. Clinicians can improve the quality of research and thus, the scientific base for practice by joining or facilitating multidisciplinary research efforts.

Fatigue and quality of life outcomes of exercise during cancer treatment.

PURPOSE: Despite the recognition of fatigue as a common and distressing symptom during cancer treatment, there are few evidence-based interventions available to manage such fatigue. The purpose of this multi-institutional pilot study was to explore the effects of a home-based moderate walking exercise intervention on fatigue, physical functioning, emotional distress, and quality of life (QOL) during breast cancer treatment. DESCRIPTION OF STUDY: Fifty-two women were recruited from five university hospital outpatient departments for this pilot study with an experimental design. Subjects were randomly assigned to the walking program or to usual care during adjuvant chemotherapy or radiation therapy for breast cancer. Symptoms, physical functioning, and QOL were measured at baseline, midtreatment, and at the end of treatment. RESULTS: Women who exercised at least 90 minutes per week on 3 or more days reported significantly less fatigue and emotional distress as well as higher functional ability and QOL than women who were less active during treatment. CLINICAL IMPLICATIONS: A home-based walking exercise program is a potentially effective, low-cost, and safe intervention to manage fatigue and to improve QOL during adjuvant chemotherapy or radiation therapy for breast cancer. This health-promoting self-care activity needs further testing in large randomized clinical trials.