Late mortality from other diseases following childhood cancer in Australia and the impact of intensity of treatment.

BACKGROUND: People who receive treatment for cancer during childhood often experience subsequent complications of therapy, known as late effects, which can lead to an increased risk of death. PROCEDURE: Using deidentified population-based data from the Australian Childhood Cancer Registry for children aged 0-14 diagnosed with cancer during the period 1983-2011 and who survived for a minimum of 5 years, we examined disease-related deaths (other than cancer recurrence or second primary cancers) that occurred up to 31 December 2016. Risk of death relative to the general population was approximated using standardised mortality ratios (SMRs). Treatment received was stratified according to the intensity of treatment rating, version 3 (ITR-3). RESULTS: During the study period, 82 noncancer disease-related deaths were recorded among 13 432 childhood cancer survivors, four times higher than expected (SMR = 4.43, 95% CI = 3.57-5.50). A clear link to treatment intensity was observed, with the relative risk of noncancer disease-related mortality being twice as high for children who underwent 'most intensive' treatment (SMR = 5.94, 95% CI = 3.69-9.55) compared to the 'least intensive' treatment group (SMR = 2.98, 95% CI = 1.42-6.24; Ptrend  = .01). Thirty-year cumulative mortality from noncancer disease-related deaths was estimated at 1.4% (95% CI = 1.1-1.9) after adjusting for competing causes of death such as cancer, accidents, or injuries. CONCLUSIONS: Although childhood cancer survivors are at increased relative risk of death from noncancer diseases, particularly those who undergo more intensive treatment, the cumulative mortality within 30 years of diagnosis remains small. Knowledge of late effects can guide surveillance of survivors and treatment modification, without wanting to compromise the high rates of survival.

Nonbreast cancer incidence, treatment received and outcomes: Are there differences in breast screening attendees versus nonattendees?

While reductions in breast cancer mortality have been evident since the introduction of population-based breast screening in women aged 50-74 years, participation in cancer screening programs can be influenced by several factors, including health system and those related to the individual. In our study, we compared cancer incidence and mortality for several cancer types other than breast cancer, noncancer mortality and patterns of treatment amongst women who did and did not participate in mammography screening. All women aged 50-65 years enrolled on the Queensland Electoral Roll in 2000 were included. The study population was then linked to records from the population-based breast screening program and private fee-for-service screening options to establish screened and unscreened cohorts. Diagnostic details for selected cancers and cause of death were obtained from the Queensland Oncology Repository. We calculated incidence rate ratios and hazard ratios comparing screened and unscreened cohorts. Among screened compared to unscreened women, we found a lower incidence of cancers of the lung, cervix, head and neck and esophagus and an increase in colorectal cancers. Cancer mortality (excluding breast cancer) was 35% lower among screened compared to unscreened women and they were also about 23% less likely to be diagnosed with distant disease. Screened compared to unscreened women were more likely to receive surgery and less likely to receive no treatment. Our study adds further to the population data examining outcomes among women participating in mammography screening.

Methods for investigating decision making in health care network meetings.

OBJECTIVE: To demonstrate a method of describing and analysing the interactions between people engaged in decision making in health care network meetings. METHOD: Analysis of the meeting interaction involved three steps: recording the meeting, annotating the verbal interactions of the meeting, and calculating various metrics from the annotations. Each annotation represented one utterance by one person. Annotations were assigned start and end times and an associated behaviour from four mutually exclusive behaviour categories. We used software and algorithms developed for this process at the Australian e-Health Research Centre. RESULTS: A meeting interaction fingerprint was produced from one meeting, which consisted of a set of metrics describing different aspects of the interaction between participants in the meeting. CONCLUSIONS: Creating meeting fingerprints and analysing the interactions between meeting participants has the potential to provide feedback to improve decision making in health care network teams.

Development and implementation of a population-based breast cancer quality index in Queensland, Australia.

BACKGROUND: While quality indicators (QI) are relatively commonplace, QIs focusing on breast cancer treatment and outcomes have not been previously developed in Australia. We describe the development and implementation of the Queensland Breast Cancer Quality Index (BCQI) and report on trends in performance indicators over time. METHODS: Development of the BCQI was overseen by a clinician-led quality assurance committee covering several clinical disciplines. Using a population-based dataset of female patients diagnosed with breast cancer from 2007 to 2016 (n = 27,541) we examined trends in indicators over time. RESULTS: The BCQI includes two quality dimensions (Effective and Accessible) and 14 indicators for public and private cancer services. Rates of re-excision following breast conservation surgery (BCS) and conversion of BCS to mastectomy reduced over time (p < 0.001 and p = 0.005, respectively). BCS was less common for women living outside a major city (p < 0.001), who had their surgery in a public (p < 0.001) or low volume hospital (p < 0.001). CONCLUSIONS: Application of the BCQI at a population-level demonstrated our results are comparable to, and in some cases superior to other jurisdictions. We identified some areas where improvement over time has occurred, while also identifying some outcomes requiring further investigation. POLICY SUMMARY: The BCQI is a well-established and valuable tool for measuring and monitoring breast cancer care. Practice indicators provide useful information to assist with identifying services performing well as well as those that may benefit from improvement.

Breast-cancer mortality in screened versus unscreened women: Long-term results from a population-based study in Queensland, Australia.

OBJECTIVE: In the context of a mature mammographic screening programme, the aim of this population-based study was to estimate rates of breast-cancer mortality among participants versus non-participants in Queensland, Australia. METHODS: The Queensland Electoral Roll was used to identify women aged 50-65 in the year 2000 (n = 269,198). Women with a prior history of invasive or in situ breast cancer were excluded (n = 6,848). The study population was then linked to mammography records from BreastScreen Queensland together with the Wesley Breast Screening Clinic (the largest provider of private screening in Queensland) to establish a screened cohort (n = 187,558) and an unscreened cohort (n = 74,792). Cohort members were matched and linked to cancer notifications and deaths through the state-based Queensland Oncology Repository. Differences in breast-cancer mortality between the two cohorts were measured using Cox proportional hazards regression. RESULTS: After 16 years of follow-up, women in the screened cohort showed a 39% reduction in breast-cancer mortality compared to the unscreened cohort (HR = 0.61, 95%CI = 0.55-0.68). Cumulative mortality over the same period was 0.47% and 0.77% in the screened and unscreened cohorts, respectively. CONCLUSIONS: This study found a significant reduction in breast-cancer mortality for women who participated in mammographic screening compared to unscreened women. Our findings of a breast-cancer mortality benefit for women who have mammographic screening are in line with other observational studies.

Towards automated observational analysis of leadership in clinical networks.

Clinical networks are being increasingly employed to drive innovation in health services by encouraging multi-disciplinary clinical engagement in management processes. The effectiveness of a network, however, depends critically on the ability of its leader to coordinate group interactions. This paper discusses leadership of clinical networks, and in this context reviews technologies for analyzing the way team members interact in group conversations. This review will form the foundation for ongoing research to develop the profile of an effective clinical network leader, along with techniques and tools for evaluation and professional development.

Patterns of care for ductal carcinoma in situ of the breast: Queensland's experience over a decade.

OBJECTIVES: To review management of ductal carcinoma in situ (DCIS) of the breast in Queensland, with reference to breast conserving surgery (BCS) and adjuvant radiation therapy (RT). In addition, we examined the incidence of invasive breast cancer recurrence and factors predictive of invasive recurrence. MATERIALS AND METHODS: A retrospective review of the Queensland Oncology Repository identified women with resected DCIS (TisN0) ± adjuvant RT between 2003 and 2012. Time to invasive breast cancer recurrence was analysed using the Kaplan Meier method. Median follow-up was 4.9 years. RESULTS: 3038 women had surgery. 940 (31%) had mastectomy and 2098 (69%) underwent BCS. Of 2098 women having BCS, 1100 (52%) received BCS alone and 998(48%) received adjuvant RT. The use of RT significantly increased over the decade from 25% to 62% (p=<0.001). Clinicopathological factors associated with RT use on multivariate analysis included age ≤70, higher socioeconomic status, larger tumour size, higher nuclear grade and surgical margins ≤5 mm. Invasive breast cancer recurrence at 5 years was 1.7% [95% CI 1.0-3.0] in RT group versus 2.8% [95% CI 2.1-3.8] in BCS alone group. Factors associated with increased risk of invasive recurrence on multivariate analysis were age <40 and surgical margins ≤2 mm. CONCLUSION: The use of adjuvant RT in Queensland significantly increased between 2003 and 2012. Selection of patients for RT was based on clinicopathological factors associated with higher recurrence risk. Although longer follow-up is required, the selective use of radiation therapy after BCS is associated with a low rate of invasive breast cancer recurrence at 5 years.

"I wish they could be in my shoes": patients' insights into tertiary health care for type 2 diabetes mellitus.

BACKGROUND: Insightful accounts of patient experience within a health care system can be valuable for facilitating improvements in service delivery. OBJECTIVE: The aim of this study was to explore patients' perceptions and experiences regarding a tertiary hospital Diabetes and Endocrinology outpatient service for the management of type 2 diabetes mellitus (T2DM). METHOD: Nine patients participated in discovery interviews with an independent trained facilitator. Patients' stories were synthesized thematically using a constant comparative approach. RESULTS: Three major themes were identified from the patients' stories: 1) understanding T2DM and diabetes management with subthemes highlighting that specialist care is highly valued by patients who experience a significant burden of diabetes on daily life and who may have low health literacy and low self confidence; 2) relationships with practitioners were viewed critical and perceived lack of empathy impacted the effectiveness of care; and 3) impact of health care systems on service delivery with lack of continuity of care relating to the tertiary hospital model and limitations with appointment bookings negatively impacting on patient experience. DISCUSSION: The patients' stories suggest that the expectation of establishing a productive, ongoing relationship with practitioners is highly valued. Tertiary clinics for T2DM are well placed to incorporate novel technological approaches for monitoring and follow-up, which may overcome many of the perceived barriers of traditional service delivery. CONCLUSION: Investing in strategies that promote patient-practitioner relationships may enhance effectiveness of treatment for T2DM by meeting patient expectations of personalized care. Future changes in service delivery would benefit from incorporating patients as key stakeholders in service evaluation.

Utilisation of outpatient cardiac rehabilitation in Queensland.

OBJECTIVES: To determine patient participation rates in outpatient cardiac rehabilitation (OCR) programs; ascertain the barriers to participation; and evaluate the quality of OCR programs. DESIGN AND SETTING: Retrospective cohort study of patient separations from selected public and private Queensland hospitals; questionnaire survey of hospitals and all registered OCR programs. PARTICIPANTS: Patients discharged with cardiac diagnoses between 1 July 1999 and 30 June 2000 from 31 hospitals (24 public; 7 private). MAIN OUTCOME MEASURES: Rates of referral of hospitalised patients to OCR programs; rates of program attendance and completion; barriers to OCR referral and attendance. RESULTS: 15 186 patients were discharged with cardiac diagnoses from participating hospitals, of whom 4346 (29%) were referred to an OCR program after discharge, compared with an estimated 59% (8895/15 186) of patients who were eligible for such a program. Proportionately more patients were referred from secondary (38% [1720/4500]) and private (52% [2116/4031]; P < 0.001) hospitals than from tertiary (25% [2626/10 686]) and public (20% [2230/11 155]) hospitals. Patients undergoing coronary revascularisation procedures comprised 35% of discharges, but accounted for 56% of all program attendances. Fewer than a third of all referred patients completed OCR programs, and only 39% of available OCR program places were fully utilised. Catchment populations of programs with unused places had excess coronary mortality. CONCLUSION: There is significant underutilisation of facility-based OCR programs in Queensland. Procedures are required for identifying and referring eligible patients to existing programs and improving program compliance. Alternative OCR models are also required.

Multisite, quality-improvement collaboration to optimise cardiac care in Queensland public hospitals.

OBJECTIVE: To evaluate changes in quality of in-hospital care of patients with either acute coronary syndromes (ACS) or congestive heart failure (CHF) admitted to hospitals participating in a multisite quality improvement collaboration. DESIGN: Before-and-after study of changes in quality indicators measured on representative patient samples between June 2001 and January 2003. SETTING: Nine public hospitals in Queensland. STUDY POPULATIONS: Consecutive or randomly selected patients admitted to study hospitals during the baseline period (June 2001 to January 2002; n = 807 for ACS, n = 357 for CHF) and post-intervention period (July 2002 to January 2003; n = 717 for ACS, n = 220 for CHF). INTERVENTION: Provision of comparative baseline feedback at a facilitative workshop combined with hospital-specific quality-improvement interventions supported by on-site quality officers and a central program management group. MAIN OUTCOME MEASURE: Changes in process-of-care indicators between baseline and post-intervention periods. RESULTS: Compared with baseline, more patients with ACS in the post-intervention period received therapeutic heparin regimens (84% v 72%; P < 0.001), angiotensin-converting enzyme inhibitors (64% v 56%; P = 0.02), lipid-lowering agents (72% v 62%; P < 0.001), early use of coronary angiography (52% v 39%; P < 0.001), in-hospital cardiac counselling (65% v 43%; P < 0.001), and referral to cardiac rehabilitation (15% v 5%; P < 0.001). The numbers of patients with CHF receiving beta-blockers also increased (52% v 34%; P < 0.001), with fewer patients receiving deleterious agents (13% v 23%; P = 0.04). Same-cause 30-day readmission rate decreased from 7.2% to 2.4% (P = 0.02) in patients with CHF. CONCLUSION: Quality-improvement interventions conducted as multisite collaborations may improve in-hospital care of acute cardiac conditions within relatively short time frames.