Cost-effectiveness analysis of imaging surveillance in stage II and III extremity soft tissue sarcoma: an Australian perspective.

BACKGROUND: Surveillance imaging is used to detect local and/or distant recurrence following primary treatment of localised soft tissue sarcoma (STS), however evidence supporting optimal surveillance modality or frequency is lacking. We used prospectively collected sarcoma data to describe current surveillance imaging practice in patients with AJCC stage II and III extremity STS and evaluate its cost-effectiveness. METHODS: From three selected Australian sarcoma referral centres, we identified patients with stage II and III extremity STS treated between 2009 and 2013. Medical records were reviewed to ascertain surveillance imaging practices, including modality, frequency and patient outcomes. A discrete event simulation model was developed and calibrated using clinical data to estimate health service costs and quality adjusted life years (QALYs) associated with alternative surveillance strategies. RESULTS: Of 133 patients treated for stage II and III extremity STS, the majority were followed up with CT chest (86%), most commonly at 3-monthly intervals and 62% of patients had the primary site imaged with MRI at 6-monthly. There was limited use of chest-X-ray. A discrete event simulation model demonstrated that CT chest screening was the most cost effective surveillance strategy, gaining additional QALYs at a mean incremental cost of $30,743. MRI alone and PET-CT alone were not cost-effective, whilst a combined strategy of CT + MRI had an incremental cost per QALY gained of $96,556. CONCLUSIONS: Wide variations were observed in surveillance imaging practices in this high-risk STS cohort. Modelling demonstrated the value of CT chest for distant recurrence surveillance over other forms of imaging in terms of cost and QALYs. Further work is required to evaluate cost-effectiveness in a prospective manner.

Accuracy and acceptability of survivorship care plans: results of a pilot study.

Survivorship treatment summaries and care plans are increasingly incorporated into cancer care but there are limited data on their accuracy and acceptability. We have evaluated written care plans developed as part of a once-off, nurse-led survivorship consultations across four medical oncology clinics in South Australia as part of a state-wide pilot. While the accuracy of treatment summaries was high, level of detail in care plans was moderate to low, as was survivors' perception of plans' utility.

DOES ONE SIZE FIT ALL? COST UTILITY ANALYSES OF ALTERNATIVE MAMMOGRAPHIC FOLLOW-UP SCHEDULES, BY RISK OF RECURRENCE.

OBJECTIVES: International guidelines recommend annual mammography after early breast cancer, but there is no randomized controlled trial evidence to support this schedule over any other. Given that not all women have the same risk of recurrence, it is possible that, by defining different risk profiles, we could tailor mammographic schedules that are more effective and efficient. METHODS: A discrete event simulation model was developed to describe the progression of early breast cancer after completion of primary treatment. Retrospective data for 1,100 postmenopausal women diagnosed with early breast cancer in South Australia from 2000 to 2008 were used to calibrate the model. Women were divided into four prognostic subgroups based on the Nottingham Prognostic Index of their primary tumor. For each subgroup, we compared the cost-effectiveness of three different mammographic schedules for two different age groups. RESULTS: Annual mammographic follow-up was not cost-effective for most postmenopausal women. Two yearly mammography was cost-effective for all women with excellent prognosis tumors; and for women with good prognosis tumors if high compliance rates can be achieved. Annual mammography for 5 years and 2 yearly surveillance thereafter (a mixed schedule) may be cost-effective for 50- to 69-year-old women with moderate prognosis tumors, and for women aged 70-79 years with poor prognosis tumors. For younger women with poor prognosis tumors, annual mammography is potentially cost-effective. CONCLUSIONS: Our results suggest that mammographic follow-up could be tailored according to risk of recurrence. If validated with larger datasets, this could potentially set the stage for personalized mammographic follow-up after breast cancer.

A patient-level calibration framework for evaluating surveillance strategies: a case study of mammographic follow-up after early breast cancer.

OBJECTIVE: Currently all women who have completed their primary treatment for early breast cancer are invited to receive routine annual mammography. There is no randomized controlled trial evidence to support this schedule, and model-based analysis is required. This paper describes a novel data collection and model calibration process to analyze the cost-effectiveness of alternative follow-up schedules for early breast cancer survivors. METHODS: A discrete event simulation model describes the progression of early breast cancer after the completion of primary treatment, representing impalpable and palpable recurrence and the detection of impalpable disease via follow-up mammography. Retrospective data from the South Australian Cancer Registry and clinical and administrative hospital databases were linked for 407 postmenopausal women diagnosed with moderate-prognosis early breast cancer from 2000 to 2008. These data formed the basis of a patient-level probabilistic calibration process. RESULTS: For 50- to 69-year-old survivors, annual follow-up for 5 years, with visits every 2 years thereafter, appears to be cost-effective. For women aged 70 to 79 years at diagnosis, a surveillance schedule similar to general population screening (2 yearly) appears to be most cost-effective if high rates of adherence can be maintained. CONCLUSIONS: This study demonstrated the potential value of combining linked, retrospective data and decision analytic modeling to provide estimates of costs and health outcomes that are sufficiently robust to inform cancer clinical guidelines and individual patient decisions regarding appropriate follow-up schedules.

Melanoma follow up: time to generate the evidence.

Research is needed into current melanoma follow-up practices and their implications for patients and society. We highlight the need and suggest a way forward.

Are clinical registries an effective tool for hospital health services to address unwarranted clinical variation?

OBJECTIVE: To map clinical registries within the Central Adelaide Local Health Network (CALHN); and to identify how these registries were currently used for addressing unwarranted clinical variation in care. METHOD: An online survey was sent to all Heads of Units (HoUs) within CALHN. The survey addressed participation, type of data, reporting processes and use of the clinical registries for research, quality assurance (QA), quality improvement (QI) and clinical variation in health care. RESULTS: Twenty-six HoUs responded (26%); 25 contributed to a clinical registry (96%); all provided data to more than one registry, but only 34.6% had an existing financial and governance arrangement with the network. Health outcomes were the most common datapoints; 77% of all data were collected manually; and 38.5% of data analysis was risk adjusted. Access to aggregated data varied across the registries; and 65.4% of reports included benchmarks and outliers. Clinical registries were used for research in 65.4%, and QA and QI in 73.1 and 69.2%, respectively. Most used external comparators and measured clinical variation, but there was marked inconsistency in the exploring clinical variation, improving care and reporting activities. CONCLUSION: Based on this sample, clinical registries within CALHN did not currently appear to be a reliable resource to consistently address unwarranted clinical variation but were shown to be valuable resources for research and quality initiatives at a high level. Further research is required to facilitate effective integration of clinical registries with administrative and quality systems.

A Mixed-Methods Systematic Review of the Effectiveness and Experiences of Quality Improvement Interventions in Radiology.

OBJECTIVE: This study aimed to compile and synthesize evidence regarding the effectiveness of quality improvement interventions in radiology and the experiences and perspectives of staff and patients. METHODS: Databases searched for both published and unpublished studies were as follows: EMBASE, MEDLINE, CINAHL, Joanna Briggs Institute, Cochrane Central Register of Controlled Trials, PsycINFO, Scopus, Web of Science, Mednar, Trove, Google Gray, OCLC WorldCat, and Dissertations and Theses. This review included both qualitative and quantitative studies of patients undergoing radiological examinations and/or medical imaging health care professionals; a broad range of quality improvement interventions including introduction of health information technology, effects of training and education, improved reporting, safety programs, and medical devices; the experiences and perspectives of staff and patients; context of radiological setting; a broad range of outcomes including patient safety; and a result-based convergent synthesis design. RESULTS: Eighteen studies were selected from 4846 identified by a systematic literature search. Five groups of interventions were identified: health information technology (n = 6), training and education (n = 6), immediate and critical reporting (n = 3), safety programs (n = 2), and the introduction of mobile radiography (n = 1), with demonstrated improvements in outcomes, such as improved operational and workflow efficiency, report turnaround time, and teamwork and communication. CONCLUSIONS: The findings were constrained by the limited range of interventions and outcome measures. Further research should be conducted with study designs that might produce findings that are more generalizable, examine the other dimensions of quality, and address the issues of cost and risk versus benefit.

A population-based study of soft tissue sarcoma incidence and survival in Australia: An analysis of 26,970 cases.

BACKGROUND: Soft tissue sarcomas (STS) are rare, often fatal tumors, but little is known of the epidemiology and survival in the Australian population. This study aims to provide the first epidemiological analysis of incidence and survival rates of STS in the Australian population. METHODS: A retrospective population-based observational study was conducted between 1982 and 2009 of all patients with a diagnosis of STS using the Australian Institute of Health and Welfare (AIHW) Australian Cancer Database. Incidence rates per 100,000; incidence rate ratios, age-standardized incidence rates, prevalence and incidence rates of subtypes of STS, median, one-year and 5-year survival rates were examined. RESULTS: A total of 26,970 patients were identified. Between 1982 and 2009 STS incidence rates significantly increased from 3.99 [95% CI 3.68-4.32] to 6.12 [95% CI 5.80-6.46] per 100,000 Australian population, with a peak incident rate ratio (IRR) of 1.59 [95% CI 1.51-1.69] (p < 0.0001) in 2001. Median age at diagnosis increased from 58 to 63 years. Incidence rates were stable across all 10-year age cohorts, except for people aged over 70 where it increased. Overall, age-standardized incidence rates increased from 4.70 [95% CI 4.42-5.00] in 1982 to 5.87 [95% CI 5.63-6.11] per 100 000 Australians in 2009. Leiomyosarcoma (20.43%), malignant fibrous histiocytoma (16.14%), and soft tissue tumors/sarcomas, not otherwise specified (10.18%) were the most common STS subtypes. Median survival from diagnosis increased from 5.80 years [95% CI 5.06-6.54] in 1985-1989 cohort to 8.18 years [95% CI 7.54-8.81] in the 2000-2004 cohort (log-rank test p < 0.0001). CONCLUSION: The incidence of STS is increasing in Australia, most noticeably in those aged over 70 years, with a small but statistically significant increase in overall survival rates.

Patterns of head and neck sarcoma in Australia.

BACKGROUND: Sarcomas affecting the head and neck often require complex management due to the combination of anatomic, aesthetic and oncological considerations. The incidence and patterns of presentation are poorly understood and have not been reviewed in the Australian population. METHOD: This study sourced incidence and demographic data from the National Cancer Registry at the Australian Institute of Health and Welfare for the years 1982-2009 (corresponding to 97.3% of the Australian population). All cases of sarcoma, according to ICD-O-3 classification ((International Classification of Diseases for Oncology, 3rd edition), were assessed. RESULTS: A total of 3911 new cases of sarcoma affecting the head and neck were recorded during the period 1982-2009, including 1383, 2106 and 442 cases arising from skin, soft tissue and bone, respectively. The annual incidence rate of sarcomas affecting the head and neck was 1.59 per 100 000 population. The incidence of head and neck sarcoma rose substantially in older age groups (age 65 years and above) and was most common in male patients (69%). Malignant fibrous histiocytoma (MFH) was the most common pathology. There was an increase in incidence in skin-origin sarcoma in the head and neck, particularly affecting elderly males. CONCLUSION: The incidence of head and neck sarcoma in Australia is higher than that reported for an equivalent European population. The increase in MFH arising from the skin in elderly male patients mirrors the patterns of common cutaneous malignancy, particularly melanoma, suggesting that ultraviolet radiation is an epidemiological factor. Management of head and neck sarcoma is complex and best managed in a specialist multidisciplinary environment.

Precision Radiology: Predicting longevity using feature engineering and deep learning methods in a radiomics framework.

Precision medicine approaches rely on obtaining precise knowledge of the true state of health of an individual patient, which results from a combination of their genetic risks and environmental exposures. This approach is currently limited by the lack of effective and efficient non-invasive medical tests to define the full range of phenotypic variation associated with individual health. Such knowledge is critical for improved early intervention, for better treatment decisions, and for ameliorating the steadily worsening epidemic of chronic disease. We present proof-of-concept experiments to demonstrate how routinely acquired cross-sectional CT imaging may be used to predict patient longevity as a proxy for overall individual health and disease status using computer image analysis techniques. Despite the limitations of a modest dataset and the use of off-the-shelf machine learning methods, our results are comparable to previous 'manual' clinical methods for longevity prediction. This work demonstrates that radiomics techniques can be used to extract biomarkers relevant to one of the most widely used outcomes in epidemiological and clinical research - mortality, and that deep learning with convolutional neural networks can be usefully applied to radiomics research. Computer image analysis applied to routinely collected medical images offers substantial potential to enhance precision medicine initiatives.

The experience of melanoma follow-up care: an online survey of patients in australia.

Investigating patients' reports on the quality and consistency of melanoma follow-up care in Australia would assist in evaluating if this care is effective and meeting patients' needs. The objective of this study was to obtain and explore the patients' account of the technical and interpersonal aspects of melanoma follow-up care received. An online survey was conducted to acquire details of patients' experience. Participants were patients treated in Australia for primary melanoma. Qualitative and quantitative data about patient perceptions of the nature and quality of their follow-up care were collected, including provision of melanoma specific information, psychosocial support, and imaging tests received. Inconsistencies were reported in the provision and quality of care received. Patient satisfaction was generally low and provision of reassurance from health professionals was construed as an essential element of quality of care. "Gaps" in follow-up care for melanoma patients were identified, particularly provision of adequate psychosocial support and patient education. Focus on strategies for greater consistency in the provision of support, information, and investigations received, may generate a cost dividend which could be reinvested in preventive and supportive care and benefit patient well-being.

Addressing "waste" in diagnostic imaging: some implications of comparative effectiveness research.

Comparative effectiveness research is intended to provide evidence to improve patient outcomes through the use of the most appropriate health technology affordable. The authors present 5 case studies, focusing on the use of plain radiography in common clinical scenarios, to illustrate the considerable scope for comparative effectiveness research within medical imaging and the different levels of evidence currently in existence to guide the improved use of medical imaging. These are blunt ankle injury, breast cancer follow-up, low back pain, routine daily chest x-rays in intensive care, and screening for breast cancer. Although there are established models for evaluating new technologies, especially pharmaceuticals, against the most commonly used current technology, the evaluation of technologies in current clinical practice is in an early phase of development. Because evaluation resources are limited, one major challenge is developing ways to identify established technologies for evaluation to refine the indications for their use. A set of criteria with which to identify established technologies that may not be delivering value for money is described, and their use is illustrated in relation to the 5 case studies. These criteria could be incorporated into literature search strategies, stakeholder consultations, and utilization scanning. Once identified, these technologies should be formally evaluated for their performance in improving patient health without restricting the availability of other effective interventions.

A multifaceted strategy for implementation of the Ottawa ankle rules in two emergency departments.

PROBLEM: Despite widespread acceptance of the Ottawa ankle rules for assessment of acute ankle injuries, their application varies considerably. DESIGN: Before and after study. BACKGROUND AND SETTING: Emergency departments of a tertiary teaching hospital and a community hospital in Australia. KEY MEASURES FOR IMPROVEMENT: Documentation of the Ottawa ankle rules, proportion of patients referred for radiography, proportion of radiographs showing a fracture. STRATEGIES FOR CHANGE: Education, a problem specific radiography request form, reminders, audit and feedback, and using radiographers as "gatekeepers." EFFECTS OF CHANGE: Documentation of the Ottawa ankle rules improved from 57.5% to 94.7% at the tertiary hospital, and 51.6% to 80.8% at the community hospital (P<0.001 for both). The proportion of patients undergoing radiography fell from 95.8% to 87.2% at the tertiary hospital, and from 91.4% to 78.9% at the community hospital (P<0.001 for both). The proportion of radiographs showing a fracture increased from 20.4% to 27.1% at the tertiary hospital (P=0.069), and 15.2% to 27.2% (P=0.002) at the community hospital. The missed fracture rate increased from 0% to 2.9% at the tertiary hospital and from 0% to 1.6% at the community hospital compared with baseline (P=0.783 and P=0.747). LESSONS LEARNT: Assessment of case note documentation has limitations. Clinician groups seem to differ in their capacity and willingness to change their practice. A multifaceted change strategy including a problem specific radiography request form can improve the selection of patients for radiography.