Healthcare Costs Before and After Diagnosis of Cancer of Unknown Primary Versus Ovarian Cancer in Australia.

BACKGROUND: Little is known about the healthcare resource usage and costs for patients with cancer of unknown primary (CUP). OBJECTIVE: The aim of this study was to describe and quantify healthcare resource use and costs in Australia, 6 months prior to and after a diagnosis of CUP, and compare to those of women with ovarian cancer. METHODS: Individual-level data combining baseline surveys, clinical records and Medicare Benefits Schedule (MBS) claim records were analysed for 149 patients with CUP and 480 patients with ovarian cancer from two prospective cohort studies. MBS data were aggregated for the period 6 months prior to diagnosis date and 6 months after diagnosis. Data included doctor consultations, pathology, diagnostics, therapeutic procedures, imaging, allied health and medicines. Generalised linear models were used to evaluate the cost differences between CUP and ovarian cancer using gamma family and log link functions. Models were adjusted for age, employment, marital status, surgery, chemotherapy and number of comorbidities. RESULTS: The mean healthcare costs in the 6 months prior to diagnosis of CUP were Australian (AU) $3903 versus AU$1327 for ovarian cancer (adjusted cost ratio 2.94, 95% confidence interval [CI] 2.08-4.15). Mean healthcare costs 6 months post-diagnosis were higher for patients with CUP versus ovarian cancer (AU$20,339 vs AU$13,819, adjusted cost ratio 1.47, 95% CI 1.13-1.92). Higher costs for patients with CUP were driven by imaging (AU$1937 vs AU$1387), procedures (AU$5403 vs AU$2702) and prescribed medicines for all conditions (AU$10,111 vs AU$6717). CONCLUSIONS: Pre-diagnosis costs for patients with CUP are nearly triple those for ovarian cancer. Six months after diagnosis, healthcare costs for CUP remained higher than for ovarian cancer due to imaging, procedures and medicines.

Pain in older adults with dementia : A survey across Europe on current practices, use of assessment tools, guidelines and policies.

BACKGROUND: We aimed to explore the existing use of pain assessment tools and guidelines, and develop understanding of the practical considerations required to facilitate their use within the nursing home, hospital and community settings. METHODS: A self-administered web-based survey was conducted with nurses, health and social care workers with an interest in the assessment of pain in older adults with cognitive impairment. The survey was distributed to participants in Austria, Belgium, Denmark, Germany, The Netherlands, Switzerland and United Kingdom. RESULTS: Only a minority of staff reported use of (inter-)national or local standards or specific pain assessment tools in daily practice. A range of tools were reported as being used, which varied across country. While participants generally reported that these pain assessment tools were easy/very easy to use, many participants reported that they were difficult to interpret. Assessment is generally performed whilst providing nursing care. This was highlighted in 70-80% of all participating countries. While many of these tools rely on facial expression of pain, facial expressions were considered to be the least useful in comparison to other items. Furthermore findings showed that nurses employed in long-term care settings did not feel that they were educated enough in pain assessment and management. CONCLUSION: Our findings suggest that pain education is required across all countries surveyed. This should include a focus on guidelines and standards for assessment and subsequent management of pain. Findings suggest that clinical staff find interpreting facial expressions in relation to pain more difficult.

The modified Memorial Symptom Assessment Scale Short Form: a modified response format and rational scoring rules.

PURPOSE: The Memorial Symptom Assessment Scale Short Form (MSAS-SF) is a widely used symptom assessment instrument. Patients who self-complete the MSAS-SF have difficulty following the two-part response format, resulting in incorrectly completed responses. We describe modifications to the response format to improve useability, and rational scoring rules for incorrectly completed items. METHODS: The modified MSAS-SF was completed by 311 women in our Peer and Nurse support Trial to Assist women in Gynaecological Oncology; the PeNTAGOn study. Descriptive statistics were used to summarise completion of the modified MSAS-SF, and provide symptom statistics before and after applying the rational scoring rules. Spearman's correlations with the Functional Assessment for Cancer Therapy-General (FACT-G) and Hospital Anxiety and Depression Scale (HADS) were assessed. RESULTS: Correct completion of the modified MSAS-SF items ranged from 91.5 to 98.7%. The rational scoring rules increased the percentage of useable responses on average 4% across all symptoms. MSAS-SF item statistics were similar with and without the scoring rules. The pattern of correlations with FACT-G and HADS was compatible with prior research. CONCLUSION: The modified MSAS-SF was useable for self-completion and responses demonstrated validity. The rational scoring rules can minimise loss of data from incorrectly completed responses. Further investigation is recommended.

Type 2 diabetes mellitus in people with severe mental illness: inequalities by ethnicity and age. Cross-sectional analysis of 588 408 records from the UK.

AIMS: To investigate whether the association of severe mental illness with Type 2 diabetes varies by ethnicity and age. METHODS: We conducted a cross-sectional analysis of data from an ethnically diverse sample of 588 408 individuals aged ≥18 years, registered to 98% of general practices (primary care) in London, UK. The outcome of interest was prevalent Type 2 diabetes. RESULTS: Relative to people without severe mental illness, the relative risk of Type 2 diabetes in people with severe mental illness was greatest in the youngest age groups. In the white British group the relative risks were 9.99 (95% CI 5.34, 18.69) in those aged 18-34 years, 2.89 (95% CI 2.43, 3.45) in those aged 35-54 years and 1.16 (95% CI 1.04, 1.30) in those aged ≥55 years, with similar trends across all ethnic minority groups. Additional adjustment for anti-psychotic prescriptions only marginally attenuated the associations. Assessment of estimated prevalence of Type 2 diabetes in severe mental illness by ethnicity (absolute measures of effect) indicated that the association between severe mental illness and Type 2 diabetes was more marked in ethnic minorities than in the white British group with severe mental illness, especially for Indian, Pakistani and Bangladeshi individuals with severe mental illness. CONCLUSIONS: The relative risk of Type 2 diabetes is elevated in younger populations. Most associations persisted despite adjustment for anti-psychotic prescriptions. Ethnic minority groups had a higher prevalence of Type 2 diabetes in the presence of severe mental illness. Future research and policy, particularly with respect to screening and clinical care for Type 2 diabetes in populations with severe mental illness, should take these findings into account.

Minority status and mental distress: a comparison of group density effects.

BACKGROUND: It has been observed that mental disorders, such as psychosis, are more common for people in some ethnic groups in areas where their ethnic group is less common. We set out to test whether this ethnic density effect reflects minority status in general, by looking at three situations where individual characteristics differ from what is usual in a locality. METHOD: Using data from the South East London Community Health study (n = 1698) we investigated associations between minority status (defined by: ethnicity, household status and occupational social class) and risk of psychotic experiences, common mental disorders and parasuicide. We used a multilevel logistic model to examine cross-level interactions between minority status at individual and neighbourhood levels. RESULTS: Being Black in an area where this was less common (10%) was associated with higher odds of psychotic experiences [odds ratio (OR) 1.34 95% confidence interval (CI) 1.07-1.67], and attempted suicide (OR 1.84 95% CI 1.19-2.85). Living alone where this was less usual (10% less) was associated with increased odds of psychotic experiences (OR 2.18 95% CI 0.91-5.26), while being in a disadvantaged social class where this was less usual (10% less) was associated with increased odds of attempted suicide (OR 1.33 95% CI 1.03-1.71). We found no evidence for an association with common mental disorders. CONCLUSIONS: The relationship between minority status and mental distress was most apparent when defined in terms of broad ethnic group but was also observed for individual household status and occupational social class.

Ethnicity and cardiovascular health inequalities in people with severe mental illnesses: protocol for the E-CHASM study.

PURPOSE: People with severe mental illnesses (SMI) experience a 17- to 20-year reduction in life expectancy. One-third of deaths are due to cardiovascular disease. This study will establish the relationship of SMI with cardiovascular disease in ethnic minority groups (Indian, Pakistani, Bangladeshi, black Caribbean, black African and Irish), in the UK. METHODS: E-CHASM is a mixed methods study utilising data from 1.25 million electronic patient records. Secondary analysis of routine patient records will establish if differences in cause-specific mortality, cardiovascular disease prevalence and disparities in accessing healthcare for ethnic minority people living with SMI exist. A nested qualitative study will be used to assess barriers to accessing healthcare, both from the perspectives of service users and providers. RESULTS: In primary care, 993,116 individuals, aged 18+, provided data from 186/189 (98 %) practices in four inner-city boroughs (local government areas) in London. Prevalence of SMI according to primary care records, ranged from 1.3-1.7 %, across boroughs. The primary care sample included Bangladeshi [n = 94,643 (10 %)], Indian [n = 6086 (6 %)], Pakistani [n = 35,596 (4 %)], black Caribbean [n = 45,013 (5 %)], black African [n = 75,454 (8 %)] and Irish people [n = 13,745 (1 %)]. In the secondary care database, 12,432 individuals with SMI over 2007-2013 contributed information; prevalent diagnoses were schizophrenia [n = 6805 (55 %)], schizoaffective disorders [n = 1438 (12 %)] and bipolar affective disorder [n = 4112 (33 %)]. Largest ethnic minority groups in this sample were black Caribbean [1432 (12 %)] and black African (1393 (11 %)). CONCLUSIONS: There is a dearth of research examining cardiovascular disease in minority ethnic groups with severe mental illnesses. The E-CHASM study will address this knowledge gap.

The Vital Role of Pathology in Improving Reproducibility and Translational Relevance of Aging Studies in Rodents.

Pathology is a discipline of medicine that adds great benefit to aging studies of rodents by integrating in vivo, biochemical, and molecular data. It is not possible to diagnose systemic illness, comorbidities, and proximate causes of death in aging studies without the morphologic context provided by histopathology. To date, many rodent aging studies do not utilize end points supported by systematic necropsy and histopathology, which leaves studies incomplete, contradictory, and difficult to interpret. As in traditional toxicity studies, if the effect of a drug, dietary treatment, or altered gene expression on aging is to be studied, systematic pathology analysis must be included to determine the causes of age-related illness, moribundity, and death. In this Commentary, the authors discuss the factors that should be considered in the design of aging studies in mice, with the inclusion of robust pathology practices modified after those developed by toxicologic and discovery research pathologists. Investigators in the field of aging must consider the use of histopathology in their rodent aging studies in this era of integrative and preclinical geriatric science (geroscience).

The assessment and management of peri-operative pain in older adults.

A number of recent reports have highlighted the inadequate provision of pain relief for older inpatients. Despite the availability of numerous validated pain measures, pain remains poorly assessed in some cases and, particularly, in the cognitively impaired. Without proper assessment, patients may receive inadequate or inappropriate analgesia, both of which can worsen outcome. Most drugs and techniques that are used for analgesia in younger patients are also suitable for older patients, although dosages may have to be adjusted to avoid the side-effects that are consequent upon age-related changes in drug pharmacokinetics and pharmacodynamics, co-morbidity, frailty, cognitive impairment and polypharmacy. This paper reviews current guidelines and methods of assessing pain in the older adult, and describes the use of, and problems with, mild, moderate, strong, adjuvant and local anaesthetic drugs in the older population for analgesia, advocating multimodal intervention to reduce dose-related side-effects, particularly of opioids.

Unmet needs in immigrant cancer survivors: a cross-sectional population-based study.

PURPOSE: Social suffering, language difficulties, and cultural factors may all make the cancer experience more difficult for immigrants. This study aimed to document unmet needs, and variables associated with these, in a population-based sample of first-generation immigrants and Anglo-Australians who had survived cancer. METHODS: Participants were recruited via Australian cancer registries. Eligible cancer survivors had a new diagnosis 1-6 years earlier and were aged between 18 and 80 years at diagnosis. Eligible immigrant participants and parents were born in a country where Arabic, Chinese (Mandarin, Cantonese, and other dialects), or Greek is spoken, and they spoke one of these languages. A random sample of English-speaking Anglo-Australian-born controls was recruited. RESULTS: Five hundred ninety-six patients (277 immigrants) were recruited to the study (response rate, 26%). Compared to Anglo-Australians, the adjusted odds ratio of Chinese immigrants for at least one unmet information/support need was 5.1 (95% CI 3.1, 8.3) and for any unmet physical need was 3.1 (95% CI 1.9, 5.1). For Greek, these were 2.0 (95% CI 1.1, 4.0) and 2.7 (95% CI 1.4, 5.2). Arabic patients had elevated, but not statistically significant, odds ratios compared to Anglo-Australians. Written information and having a specialist, support services, and other health professionals who spoke their language were in the top ten unmet needs amongst immigrants. CONCLUSION: Immigrant cancer survivors, several years after initial diagnosis, are more likely to have an unmet need for information or for help with a physical problem than Anglo-Australians. They strongly desire information and support in their own language.

Clinical and cost-effectiveness analysis of an open label, single-centre, randomised trial of spinal cord stimulation (SCS) versus percutaneous myocardial laser revascularisation (PMR) in patients with refractory angina pectoris: The SPiRiT trial.

BACKGROUND: Patients with refractory angina have significant morbidity. This study aimed to compare two of the treatment options, Spinal Cord Stimulation (SCS) and Percutaneous Myocardial Laser Revascularisation (PMR) in terms of clinical outcomes and cost-effectiveness. METHODS: Eligible patients were randomised to PMR or SCS and followed up for exercise tolerance time (ETT), Canadian Cardiovascular Society (CCS) classification and the quality of life measures SF-36, Seattle Angina Questionnaire and the EuroQoL at 3, 12 and 24 months. Utilities were calculated using the EQ-5D and these and costs were compared between groups. The incremental cost-effectiveness ratio (ICER) per QALY for SCS compared to PMR was also calculated. RESULTS: At 24 months post-randomisation, patients that had SCS and PMR had similar ETT (mean difference 0.05, 95% CI -2.08, 2.18, p = 0.96) and there was no difference in CCS classification or quality of life outcomes. The difference in overall mean costs when comparing SCS to PMR was GBP5,520 (95% CI GBP1,966 to GBP8,613; p < 0.01) and the ICER of using SCS was GBP46,000 per QALY. CONCLUSION: Outcomes after SCS did not differ appreciably from those after PMR, with the former procedure being less cost-effective as currently applied. Larger studies could clarify which patients would most benefit from SCS, potentially increasing cost-effectiveness. TRIAL REGISTRATION: Current Controlled Trials ISRCTN09648950.

The assessment of pain in older people.

Pain is under-recognised and under-treated in older people. It is a subjective, personal experience, only known to the person who suffers. The assessment of pain is particularly challenging in the presence of severe cognitive impairment, communication difficulties or language and cultural barriers. These guidelines set out the key components of assessing pain in older people, together with a variety of practical scales that may be used with different groups, including those with varying levels of cognitive or communication impairment. The purpose is to provide professionals with a set of practical skills to assess pain as the first step towards its effective management. The guidance has implications for all healthcare and social care staff and can be applied in all settings, including the older person's own home, in care homes, and in hospital.

Do oncologists discuss expensive anti-cancer drugs with their patients?

BACKGROUND: In Australia, some anti-cancer drugs are only available at significant financial cost to patients. We sought the views and practices of Australian medical oncologists regarding discussion of high cost drugs (HCDs). PARTICIPANTS AND METHODS: A postal survey was mailed to all 274 members of the Medical Oncology Group of Australia. Three clinical scenarios described HCDs associated with either improved overall survival, encouraging response rate in a treatment-refractory cancer, or a scenario with improved treatment tolerability. Participants were asked about their discussion and prescription of HCDs. RESULTS: There was a 78% response rate. Most respondents were male (71%), worked in a metropolitan practice (87%) and spent more than 50% of their working time in patient care (87%). Forty-eight percent had previously prescribed a HCD. In the three scenarios, respondents would generally prescribe the drug if it were subsidised, however, between 28% and 41% (depending on the scenario) would not mention the HCD if it were not subsidised. Major reasons for not mentioning the HCD were concerns that discussion would 'worry the patient' or that the doctor would 'feel bad'. CONCLUSIONS: Despite literature suggesting that patients wish to be well informed and active participants in decision making, the practice of a significant percentage of Australian medical oncologists may prevent this.

Mapping the quality of life and unmet needs of urban women with metastatic breast cancer.

Enhancing quality of life and reducing the unmet needs of women are central to the successful management of advanced breast cancer. The objective of this study was to investigate the quality of life and support and information needs of urban women with advanced breast cancer. This study was conducted at four large urban hospitals in Melbourne, Australia. A consecutive sample of 105 women with advanced breast cancer completed a questionnaire that contained the European Organization of Research and Treatment of Cancer Quality of Life Q-C30 and the Supportive Care Needs Survey. Between one quarter and a third of the women reported difficulties with their physical, role and social functioning, and a little over a quarter of the women reported poor global health status. Fatigue was a problem for most women. The highest unmet needs were in the psychological and health information domains. Almost no differences in unmet needs were detected when comparing different demographic and disease characteristics of women. Health care providers should routinely monitor the quality of life and needs of women with advanced breast cancer to ensure that appropriate treatment, information or supportive services are made available.

Validation of the cancer needs questionnaire (CNQ) short-form version in an ambulatory cancer setting.

The short-form Cancer Needs Questionnaire (CNQ) is a self-administered cancer-specific questionnaire designed to assess patients' needs across several domains. The purpose of this study is to further evaluate its internal consistency and construct validity, in a group of ambulatory patients with cancer. Four hundred and fifty patients with a variety of cancer types participated. Factor analysis reproduced five domains: psychological; health information; physical and daily living; patient care and support; and interpersonal communication needs. Cronbach's alpha coefficients ranged from 0.94 to 0.77, indicating substantial consistency across items grouped in the five domains. A priori predictions regarding convergent and contrasting groups construct validity were explored using bivariate relationships between domains of the short-form CNQ, the EORTC QLQC-30 and Beck Depression Inventory (short-form), with support provided for most of the predictions. The current study provides supportive evidence that the short-form CNQ is a reliable and valid instrument for assessing the needs of patients with cancer in an ambulatory care setting.

Social position and minor psychiatric morbidity over time in the British Household Panel Survey 1991-1998.

STUDY OBJECTIVE: To examine social inequalities in minor psychiatric morbidity as measured by the GHQ-12 using lagged models of psychiatric morbidity and changing job status. DESIGN: GHQ scores were modelled using two level hierarchical regression models with measurement occasions nested within individuals. The paper compares and contrasts three different ways of describing social position: income, social advantage and lifestyle (the Cambridge scale), and social class (the new National Statistics Socio-Economic Classification), and adjusts for attrition. SETTING: Survey interviews for a nationally representative sample of adults of working age living in Britain. PARTICIPANTS: 8091 original adult respondents in 1991 who remain of working age during 1991-1998 from the British Household Panel Survey (BHPS). MAIN RESULTS: There was a relation of GHQ-12 to social position when social position was combined with employment status. This relation itself varied according to a person's psychological health in the previous year. CONCLUSIONS: The relation between social position and minor psychiatric morbidity depended on whether or not a person was employed, unemployed, or economically inactive. It was stronger in those with previously less good psychological health. Among employed men and women in good health, GHQ-12 varied little according to social class, status, or income. There was a "classic" social gradient in psychiatric morbidity, with worse health in less advantaged groups, among the economically inactive. Among the unemployed, a "reverse" gradient was found: the impact of unemployment on minor psychiatric morbidity was higher for those who were previously in a more advantaged social class position.

Social inequalities in health by individual and household measures of social position in a cohort of healthy people.

STUDY OBJECTIVE: It is increasingly recognised that different dimensions of social inequality may be linked to health by different pathways. Furthermore, factors operating at the individual level such as employment conditions may affect health in a different way from household level factors. The paper examines the associations between self rated health and four measures of social position- occupational class, household social advantage, personal and household income. DESIGN: Multilevel logistic regression models were used to predict self rated health using longitudinal data from the British Household panel survey (BHPS) with respondents nested within households. Separate analyses were carried out for economically active and inactive respondents. SETTING: Interview based surveys of adults living within households that are representative of British households. PARTICIPANTS: Adult respondents from the BHPS. MAIN RESULTS: Occupational class has relatively strong effects on the self rated health of the economically active, although household level factors also seem to influence their health. Household social advantage has relatively strong effects on the self rated health of the economically inactive. CONCLUSIONS: The paper found evidence in support of the view that different dimensions of social inequality have different pathways to self rated health. There are unexplained similarities in health between household members, which require further investigation.

A UK trial-based cost--utility analysis of transmyocardial laser revascularization compared to continued medical therapy for treatment of refractory angina pectoris.

OBJECTIVE: Transmyocardial laser revascularization (TMLR) is used to treat patients with refractory angina considered unsuitable for conventional forms of revascularization. Using patient specific data from a single centre UK randomised-controlled trial, we aimed to determine whether, from a UK National Health Service (NHS) perspective, TMLR plus standard medical management is cost-effective when compared with standard medical management alone. METHODS: One hundred and eighty-eight patients assessed as having refractory angina, and not suitable for conventional forms of revascularization were randomized to receive TMLR and medical management (94) or medical management alone (94). Costs to the UK NHS of TMLR (where appropriate), and all secondary sector health care contacts and cardiac-related medication in the 12 months following randomization, were collected. Patient utility as measured using the EuroQol EQ-5D questionnaire was combined with 12-month survival data to generate quality adjusted life years (QALYs). RESULTS: The mean cost per patient over the year from hospitalization for TMLR was 11,470 pounds sterling and for medical management alone was 2586 pounds sterling, giving a cost difference of 8901 pounds sterling (95% confidence interval (CI) 7502 pounds sterling--10,008 pounds sterling: P < 0.0001). The mean QALY difference, in favour of TMLR was 0.039 (95% CI -0.033 to 0.113: P = 0.268). This gives an incremental cost per QALY of over 228,000 pounds sterling. Analysis of stochastic uncertainty and of sensitivity to gross changes in key parameters consistently produces very high costs per QALY. CONCLUSIONS: The policy implications are clear: for such patients TMLR is an inefficient use of UK health service resources. This conclusion would not be changed by considerable improvements in effectiveness or reductions in cost.

Cognitive function in nondemented older women who took estrogen after menopause.

Investigations of the effects of estrogen replacement on cognitive function in healthy older women have yielded disparate results. We evaluated the relationship between a history of estrogen use and cognitive test performance in 727 women participating in a large community-based study. Participants were followed longitudinally for an average of 2.5 years. Estrogen use history was obtained at baseline. Standardized tests of memory, language, and abstract reasoning were administered at baseline and at follow-up. Results indicate that women who had used estrogen replacement scored significantly higher on cognitive testing at baseline than nonusers, and their performance on verbal memory improved slightly over time. The effect of estrogen on cognition was independent of age, education, ethnicity, and APOE genotype. Results suggest that estrogen replacement therapy may help to maintain cognitive function in nondemented postmenopausal women.

Cross-cultural neuropsychological assessment: a comparison of randomly selected, demographically matched cohorts of English- and Spanish-speaking older adults.

As the US population of elderly Hispanics continues to grow, there is an increasingly greater need for neuropsychological measures that are appropriate for assessing Spanish-speaking elders. The current study compared the performance of randomly selected, community-based samples of English- and Spanish-speaking elders on a brief neuropsychological test battery. Subject groups were matched for age and education. Multivariate analysis indicated significant group differences on the test battery. English and Spanish speakers scored comparably on many language-based tasks, but Spanish speakers scored significantly lower on almost all of the nonverbal measures. Significant group differences were observed on multiple-choice matching and recognition memory for stimuli from the Benton Visual Retention Test, as well as on Identities and Oddities from the Mattis Dementia Rating Scale, category fluency, and Complex Ideational Material from the Boston Diagnostic Aphasia Examination (BDAE). Results suggest that caution is warranted when using nonverbal as well as verbal measures to assess non-English-speaking individuals.