Pan-Canadian consensus recommendations for proton beam therapy access in Canada.

PURPOSE: Proton Beam Therapy (PBT)is a treatment option for select cancer patients. It is currently not available in Canada. Assessment and referral processes for out-of-country treatment for eligible patients vary by jurisdiction, leading to variability in access to this treatment for Canadian cancer patients. The purpose of this initiative was to develop a framework document to inform consistent and equitable PBT access for appropriate patients through the creation of pan-Canadian PBT access consensus recommendations. MATERIALS AND METHODS: A modified Delphiprocess was used to develop pan-Canadian recommendations with input from 22 PBT clinical and administrative experts across all provinces, external peer-review by provincial cancer and system partners, and feedback from a targeted community consultation. This was conducted by electronic survey and live discussion. Consensus threshold was set at 70% agreement. RESULTS: Fourconsensus rounds resulted in a final set of 27 recommendations divided into three categories: patient eligibility (n = 9); program level (n = 10); and system level (n = 8). Patient eligibility included: anatomic site (n = 4), patient characteristics (n = 3), clinical efficacy (n = 2). Program level included: regulatory and staff requirements (n = 5), equipment and technologies (n = 4), quality assurance (n = 1). System level included: referral process (n = 5), costing, budget impact and quality adjusted life years (n = 2), eligible patient estimates (n = 1). Recommendations were released nationally in June 2021 and distributed to all 43 cancer programs in Canada. CONCLUSION: A pan-Canadian consensus-building approach was successful in creating an evidence-based, peer-reviewed suite of recommendations thatsupportapplication of consistent clinical criteria to inform treatment options, facility set-up and access to high quality proton therapy.

Challenges and advice for MD/PhD applicants who are underrepresented in medicine.

The importance of diversity is self-evident in medicine and medical research. Not only does diversity result in more impactful scientific work, but diverse teams of researchers and clinicians are necessary to address health disparities and improve the health of underserved communities. MD/PhD programs serve an important role in training physician-scientists, so it is critical to ensure that MD/PhD students represent diverse backgrounds and experiences. Groups who are underrepresented in medicine and the biomedical sciences include individuals from certain racial and ethnic backgrounds, individuals with disabilities, individuals from disadvantaged backgrounds, and women. However, underrepresented students are routinely discouraged from applying to MD/PhD programs due to a range of factors. These factors include the significant cost of applying, which can be prohibitive for many students, the paucity of diverse mentors who share common experiences, as well as applicants' perceptions that there is inadequate support and inclusion from within MD/PhD programs. By providing advice to students who are underrepresented in medicine and describing steps programs can take to recruit and support minority applicants, we hope to encourage more students to consider the MD/PhD career path that will yield a more productive and equitable scientific and medical community.

Examination of Health System Resources and Costs Associated With Transitioning Cancer Survivors to Primary Care: A Propensity-Score-Matched Cohort Study.

BACKGROUND:: Transitioning low-risk cancer survivors back to their primary care provider (PCP) has been shown to be safe but the effect on health system resources and costs has not been examined. METHODS:: A Well Follow-Up Care Initiative (WFCI) was implemented in the publicly funded health system. Low-risk breast cancer (BC) survivors in the WFCI intervention group were transitioned from oncologist-led cancer clinics to PCPs. We compared health system costs ($2,014 in Canadian dollars) and resource utilization in this intervention group with that in propensity-score-matched nontransitioned BC survivors (ie, controls) diagnosed in the same year, with similar disease profile and patient characteristics using publicly funded administrative databases. RESULTS:: A total of 2,324 BC survivors from the WFCI intervention group were 1:1 matched to controls and observed for 25 months. Compared with controls, survivors in the intervention group incurred a similar number of PCP visits (6.9 v 7.5) and fewer oncologist visits (0.3 v 1.2) per person-year. Fewer survivors in the intervention group (20.1%) were hospitalized than in the control group (24.4%). There were no differences in emergency visits. More survivors in the intervention group had mammograms (82.6% v 73.1%), but other diagnostic tests were less frequent. There was a 39.3% reduction in overall mean annual costs ($6,575 v $10,832) and a 22.1% reduction in overall median annual costs ($2,261 v $2,903). Overall survival in the intervention group was not worse than controls. CONCLUSION:: Transitioning low-risk BC survivors to PCPs was associated with lower health system resource use and a lower annual cost per patient than matched controls. The WFCI model represents a reasonable approach at the population level to delivering quality care for low-risk BC survivors that seems to be cost effective.

Oncology care provider perspectives on exercise promotion in people with cancer: an examination of knowledge, practices, barriers, and facilitators.

BACKGROUND: Despite the reported benefits of physical activity in alleviating the impact of cancer and its treatments, oncology care providers (OCPs) are not routinely discussing exercise with their patients, suggesting a knowledge to action gap. We sought to determine OCP's knowledge, beliefs, barriers, and facilitators to exercise discussion. METHODS: A survey was administered to OCPs at the cancer center in Hamilton, Ontario. Questions comprised of demographics, knowledge and beliefs regarding exercise guidelines, and barriers and facilitators to exercise discussion. Analysis of survey responses was descriptive. Pearson's chi-squared test was used to examine select associations. RESULTS: There were 120 respondents (61% response rate) representing a diversity of professions. Approximately, 80% of OCPs were not aware of any exercise guidelines in cancer and self-reported poor knowledge on when, how, and which patients to refer to exercise programs. OCPs who reported meeting Canada's Physical Activity guidelines were significantly more likely to identify correct guidelines (p = 0.023) and to report good knowledge on how to provide exercise counseling (p = 0.014). Across OCP groups, barriers to exercise discussion included poor knowledge, lack of time, and safety concerns. Most felt that educational sessions and having an exercise specialist on the clinical team would be beneficial. CONCLUSIONS: OCPs have low knowledge regarding exercise counseling, but believe that discussing exercise is a multidisciplinary task and expressed a desire for further training. Interventions will require a multi-pronged approach including education for OCPs and guidance on assessment for exercise safety.

Impact of research investment on scientific productivity of junior researchers.

There is a demand for providing evidence on the effectiveness of research investments on the promotion of novice researchers' scientific productivity and production of research with new initiatives and innovations. We used a mixed method approach to evaluate the funding effect of the New Investigator Fund (NIF) by comparing scientific productivity between award recipients and non-recipients. We reviewed NIF grant applications submitted from 2004 to 2013. Scientific productivity was assessed by confirming the publication of the NIF-submitted application. Online databases were searched, independently and in duplicate, to locate the publications. Applicants' perceptions and experiences were collected through a short survey and categorized into specified themes. Multivariable logistic regression was performed. Odds ratios (OR) with 95 % confidence intervals (CI) are reported. Of 296 applicants, 163 (55 %) were awarded. Gender, affiliation, and field of expertise did not affect funding decisions. More physicians with graduate education (32.0 %) and applicants with a doctorate degree (21.5 %) were awarded than applicants without postgraduate education (9.8 %). Basic science research (28.8 %), randomized controlled trials (24.5 %), and feasibility/pilot trials (13.3 %) were awarded more than observational designs (p < 0.001). Adjusting for applicants and application factors, awardees published the NIF application threefold more than non-awardees (OR = 3.4, 95 %, CI = 1.9, 5.9). The survey response rate was 90.5 %, and only 58 % commented on their perceptions, successes, and challenges of the submission process. These findings suggest that research investments as small as seed funding are effective for scientific productivity and professional growth of novice investigators and production of research with new initiatives and innovations. Further efforts are recommended to enhance the support of small grant funding programs.

The expanding role of primary care in cancer control.

The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise­from epidemiologists, psychologists, policy makers, and cancer specialists­has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care­its continuous, coordinated, and comprehensive care for individuals and families­are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.

Supporting models to transition breast cancer survivors to primary care: formative evaluation of a cancer care Ontario initiative.

PURPOSE: Many breast cancer (BC) survivors continue to be seen by specialists for routine follow-up care despite growing evidence that transitioning appropriate BC survivors to primary care is safe and effective. We describe the formative evaluation of an initiative involving the development and implementation of sustainable models of follow-up care for BC survivors across 14 Regional Cancer Centers (RCC) in Ontario, Canada. METHODS: After extensive consultation, each RCC received catalyst funding for the initiative. Detailed work plans were developed locally and submitted to Cancer Care Ontario. Each region had a designated lead and support from primary care. Funding could be used to develop any aspect of the model. Formative evaluation of each model was conducted with descriptive analysis of the model created, including summative description of how resources were used, the number of survivors transitioned, and preliminary results from patient surveys of experience at transition. RESULTS: Each region developed a unique model that included clearly identified structures and processes of care. All regions used survivorship care plans and patient education materials. Three main models of follow-up care were developed: (1) direct to primary care, (2) transition clinic, and (3) shared care. A total of 3,418 BC survivors transitioned between March 2012 and September 2013. Patient experience surveys were distributed by 12 regions, gathering responses from 752 BC survivors, with 85% reporting that they felt adequately prepared for the transition. CONCLUSION: Using the approach described, wide-scale transition of appropriate BC survivors from oncology-led practice is feasible over a fairly short timeframe.

Gemcitabine/dexamethasone/cisplatin vs cytarabine/dexamethasone/cisplatin for relapsed or refractory aggressive-histology lymphoma: cost-utility analysis of NCIC CTG LY.12.

BACKGROUND: The NCIC CTG LY.12 study showed that gemcitabine, dexamethasone, and cisplatin (GDP) were noninferior to dexamethasone, cytarabine, and cisplatin (DHAP) in patients with relapsed or refractory aggressive histology lymphoma prior to autologous stem cell transplantation. We conducted an economic evaluation from the perspective of the Canadian public healthcare system based on trial data. METHODS: The primary outcome was an incremental cost utility analysis comparing costs and benefits associated with GDP vs DHAP. Resource utilization data were collected from 519 Canadian patients in the trial. Costs were presented in 2012 Canadian dollars and disaggregated to highlight the major cost drivers of care. Benefit was measured as quality-adjusted life-years (QALYs) based on utilities translated from prospectively collected quality-of-life data. All statistical tests were two-sided. RESULTS: The mean overall costs of treatment per patient in the GDP and DHAP arms were $19 961 (95% confidence interval (CI) = $17 286 to $24 565) and $34 425 (95% CI = $31 901 to $39 520), respectively, with an incremental difference in direct medical costs of $14 464 per patient in favor of GDP (P < .001). The predominant cost driver for both treatment arms was related to hospitalizations. The mean discounted quality-adjusted overall survival with GDP was 0.161 QALYs and 0.152 QALYs for DHAP (difference = 0.01 QALYs, P = .146). In probabilistic sensitivity analysis, GDP was associated with both cost savings and improved quality-adjusted outcomes compared with DHAP in 92.6% of cost-pair simulations. CONCLUSIONS: GDP was associated with both lower costs and similar quality-adjusted outcomes compared with DHAP in patients with relapsed or refractory lymphoma. Considering both costs and outcomes, GDP was the dominant therapy.

Cancer patients' function, symptoms and supportive care needs: a latent class analysis across cultures.

PURPOSE: Patient-reported outcomes (PROs) are an umbrella term covering a range of outcomes, including symptoms, functioning, health-related quality of life, and supportive care needs. Research regarding the appropriate PRO questionnaires to use is informative. A previously published latent class analysis (LCA) examined patterns of function, symptoms, and supportive care needs in a sample of US cancer patients. The current analysis investigated whether the findings from the original study were replicated in new samples from different countries and whether a larger sample combining all the data would affect the classes identified. METHODS: This secondary analysis of data from 408 Japanese and 189 Canadian cancer patients replicated the methods used in the original LCA using data from 117 US cancer patients. In all samples, subjects completed the EORTC-QLQ-C30 and Supportive Care Needs Survey Short Form-34 (SCNS-SF34). We first dichotomized individual function, symptom, and need domain scores. We then performed LCA to investigate the patterns of domains for each of the outcomes, both in the individual country samples and then combining the data from all three samples. RESULTS: Across all analyses, class assignment was made by level of function, symptoms, or needs. In individual samples, only two-class models ("high" vs. "low") were generally identifiable while in the combined sample, three-class models ("high" vs. "moderate" vs. "low") best fit the data for all outcomes. CONCLUSIONS: In this analysis, the level of burden experienced by patients was the key factor in defining classes.

Factors associated with not receiving homecare, end-of-life homecare, or early homecare referral among cancer decedents: A population-based cohort study.

Publicly funded homecare has been shown to reduce acute care use and improve quality of life for those nearing end-of-life (EOL). Yet despite the known benefits of homecare, many EOL cancer patients never receive these services. We used administrative data on all cancer decedents in Ontario, Canada in 2006 to determine predictive factors of not receiving homecare, not receiving EOL homecare, and late initiation of EOL homecare. 22,262 decedents met the eligibly criteria, 25% of whom never received homecare in the last six months of life. A logistic regression found that cancer disease site, having a comorbidity (OR: 1.15, 95% CI: 1.1-1.2), region of residence, shorter cancer survival (OR: 2.09, 95% CI: 1.8-2.4), being male (OR: 1.25, 95% CI: 1.2-1.3), lower income (OR: 1.06, 95% CI: 1.03-1.08), older age (OR: 1.03, 95% CI: 1.02-1.05), and less prior emergency department use were significant factors associated with not receiving homecare (p<0.001). Individuals with hematological cancer (OR: 1.57, 95% CI: 1.3-1.8) were less likely to receive homecare in their final months. Some of these covariates also predicted not receiving EOL homecare and late referral to these services (p<0.05). The systematic differences in homecare use that we identified can help to guide strategies for improving access to these important services.

Identifying changes in scores on the EORTC-QLQ-C30 representing a change in patients' supportive care needs.

PURPOSE: Using health-related quality-of-life measures for patient management requires knowing what changes in scores require clinical attention. We estimated changes on the European Organization for Research and Treatment of Cancer Quality-of-Life-Questionnaire-Core-30 (EORTC-QLQ-C30), representing important changes by comparing to patient-reported changes in supportive care needs. METHODS: This secondary analysis used data from 193 newly diagnosed cancer patients (63 % breast, 37 % colorectal; mean age 60 years; 20 % male) from 28 Canadian surgical practices. Participants completed the Supportive Care Needs Survey-Short Form-34 (SCNS-SF34) and EORTC-QLQ-C30 at baseline, 3, and 8 weeks. We calculated mean changes in EORTC-QLQ-C30 scores associated with improvement, worsening, and no change in supportive care needs based on the SCNS-SF34. Mean changes in the EORTC-QLQ-C30 scores associated with the SCNS-SF34 improved and worsened categories were used to estimate clinically important changes, and the 'no change' category to estimate insignificant changes. RESULTS: EORTC-QLQ-C30 score changes ranged from 6 to 32 points for patients reporting improved supportive care needs; statistically significant changes were 10-32 points. EORTC-QLQ-C30 score changes ranged from 21-point worsening to 21-point improvement for patients reporting worsening supportive care needs; statistically significant changes were 9-21 points in the hypothesized direction and a 21-point statistically significant change in the opposite direction. EORTC-QLQ-C30 score changes ranged from a 1-point worsening to 16-point improvement for patients reporting stable supportive care needs. CONCLUSION: These data suggest 10-point EORTC-QLQ-C30 score changes represent changes in supportive care needs. When using the EORTC-QLQ-C30 in clinical practice, scores changing ≥10 points should be highlighted for clinical attention.

Robotic radiosurgery for the treatment of 1-3 brain metastases: a pragmatic application of cost-benefit analysis using willingness-to-pay.

With the emergence of radiosurgery as a new radiotherapeutic technique, health care decision makers are required to incorporate community need, cost and patient preferences when allocating radiosurgery resources. Conventional patient utility measures would not reflect short term preferences and would therefore not inform decision makers when allocating radiosurgery treatment units. The goal of this article is to demonstrate the feasibility of cost-benefit analysis to elicit the yearly net monetary benefit of robotic radiosurgery. To calculate the yearly incremental cost of robotic radiosurgery as compared to fixed gantry radiosurgery we used direct local cost data. We assumed a standard 10 year replacement and 5% amortization rate. Decision boards summarizing the clinical scenario of brain metastases and the difference between robotic and fixed gantry radiosurgery in terms of immobilization, comfort and treatment time were then presented to a sample of 18 participants. Participants who preferred robotic radiosurgery were randomly assigned to either a low ($1) or high ($5) starting point taxation based willingness-to-pay algorithm. The yearly incremental cost of providing robotic radiosurgery was $99,177 CAD. The mean community yearly willingness-to-pay for robotic radiosurgery was $2,300,000 CAD, p = 0.03. The calculated yearly net societal benefit for robotic radiosurgery was $2,200,823 CAD. Among participants who preferred robotic radiosurgery there was no evidence of starting point bias, p = 0.8. We have shown through this pilot study that it is feasible to perform cost-benefit analysis to evaluate new technologies in Radiation Oncology. Cost-benefit analysis offers an analytic method to evaluate local preferences and provide accountability when allocating limited healthcare resources.

A Pan-Canadian practice guideline: prevention, screening, assessment, and treatment of sleep disturbances in adults with cancer.

PURPOSE: This study aims to provide recommendations on the optimal strategies and interventions for the prevention, screening, assessment, and management of cancer-related sleep disturbance (insomnia and insomnia syndrome) in adult cancer populations. METHODS: A systematic search of the published health literature was conducted to identify randomized controlled trials, clinical practice guidelines, systematic reviews, and other guidance documents. The Sleep Disturbance Expert Panel [comprised of nurses, psychologists, primary care physicians, oncologists, physicians specialized in sleep disturbances, researchers, and guideline methodologists] reviewed, discussed, and approved the final version of the guideline. Health care professionals across Canada were asked to provide feedback through an external review process. RESULTS: Three clinical practice guidelines and 12 randomized controlled trials were identified as the evidence base. Overall, despite the paucity of evidence, the evidence and expert consensus suggest that it is important to screen and assess adult cancer patients for sleep disturbances using standardized screening tools on a routine basis. While prevention of sleep disturbance is the desired objective, cognitive behavioral therapies are effective in improving sleep outcomes. As part of the external review with 16 health care providers, 81 % indicated that they agreed with the recommendations as written. CONCLUSIONS: Sleep difficulty is a prevalent problem in cancer populations that needs greater recognition by health professionals. Prevention, screening, assessment, and treatment strategies supported by the best available evidence are critical. Recommendations and care path algorithms for practice are offered.

Advanced lung cancer patients' experience with continuity of care and supportive care needs.

As cancer care becomes increasingly complex, the ability to coordinate this care is more difficult for health care providers, patients and their caregivers alike. Despite the widely recognized need for improving continuity and coordination of care, the relationship of continuity of care with patient outcomes has yet to be elucidated. Our study's main finding is that the Continuity and Coordination subscale of the widely used Picker System of Ambulatory Cancer Care Survey is able to distinguish between lung cancer patients with unmet supportive care needs and those without. Specifically, this study shows a new association between this widely implemented continuity and coordination survey and the 'psychological needs' domain, as well as the 'health system and information' domains of supportive care needs. The finding provides support for the idea that interventions to improve continuity may impact tangible indicators of patient care such as supportive care needs being met. The study focuses attention on continuity of care as an important aspect of optimizing outcomes in cancer care.

A randomized phase 3 trial of thalidomide and prednisone as maintenance therapy after ASCT in patients with MM with a quality-of-life assessment: the National Cancer Institute of Canada Clinicals Trials Group Myeloma 10 Trial.

We conducted a randomized, controlled trial comparing thalidomide-prednisone as maintenance therapy with observation in 332 patients who had undergone autologous stem cell transplantation with melphalan 200 mg/m2. The primary end point was overall survival (OS); secondary end points were myeloma-specific progression-free survival,progression-free survival, incidence of venous thromboembolism, and health-related quality of life (HRQoL). With a median follow-up of 4.1 years, no differences in OS between thalidomide-prednisone and observation were detected (respective 4-year estimates of 68% vs 60%, respectively; hazard ratio = 0.77; P = .18); thalidomide-prednisone was associated with superior myeloma-specific progression-free survival and progression-free survival (for both outcomes, the 4-year estimates were 32% vs 14%; hazard ratio = 0.56; P < .0001) and more frequent venous thromboembolism (7.3% vs none; P = .0004). Median survival after first disease recurrence was 27.7 months with thalidomide-prednisone and 34.1 months in the observation group. Nine second malignancies were observed with thalidomide-prednisone versus 6 in the observation group. Those allocated to thalidomide-prednisone reported worse HRQoL with respect to cognitive function, dyspnea, constipation, thirst, leg swelling, numbness, dry mouth, and balance problems. We conclude that maintenance therapy with thalidomide-prednisone after autologous stem cell transplantation improves the duration of disease control, but is associated with worsening of patient-reported HRQoL and no detectable OS benefit.

Modeling the longitudinal transitions of performance status in cancer outpatients: time to discuss palliative care.

CONTEXT: Understanding the longitudinal transitions of performance status among persons with cancer can assist providers in determining the appropriate time to initiate palliative care support. OBJECTIVES: To model longitudinal transitions of performance status in cancer outpatients, to determine the probabilities of improvement and deterioration in performance status over time, and to evaluate the factors associated with rates of transitions. METHODS: This population-based, retrospective, cohort study comprised adult outpatients diagnosed with any type of cancer and assessed for performance status throughout their observation period using the Palliative Performance Scale (PPS; scale 0-100; 0 indicates death). At every PPS assessment, patients were assigned to one of four states: stable state (PPS score 70-100), transitional state (PPS score 40-60), end-of-life state (PPS score 10-30), or dead. A Markov multistate model under the presence of interval censoring was used to examine the rate of state-to-state transitions. RESULTS: There were 11,374 patients representing nearly 71,000 assessments. Patients with lung cancer in the transitional state had a 27.7% chance of being dead at the end of one month vs. 17.5% in patients with breast cancer. The average time spent in the transitional state was 6.6 weeks for patients diagnosed with gastrointestinal cancer vs. 8.8 weeks for patients with breast cancer. The rate at which one moves from the transitional state to death was higher for patients with lung cancer than those with breast cancer. CONCLUSION: We estimated the probability and direction of change in performance status in cancer outpatients. Entry into the transitional state may serve as an indicator for referral for palliative care support. Mean end-of-life sojourn times are too short to allow meaningful integration of palliative care.

Opioid prescription after pain assessment: a population-based cohort of elderly patients with cancer.

PURPOSE: The purpose of this study was to measure opioid prescription (OP) rates in elderly cancer outpatients around the time of assessment for pain and to evaluate factors associated with receiving OPs for those with severe pain. PATIENTS AND METHODS: The cross-sectional cohort includes all patients with cancer in Ontario older than age 65 years who completed a pain assessment as part of a provincial initiative of systematic symptom screening. Patients were assigned to mutually exclusive categories by pain score severity: 0, 1 to 3 (mild), 4 to 6 (moderate), and 7 to 10 (severe). We linked multiple provincial health databases to examine the proportion of patients with an OP within 7 days after or 30 days before the assessment date. We examined factors associated with OPs for patients with pain scores of 7 to 10. RESULTS: The proportion of patients with an OP increased as pain score severity increased: 10% of those with no pain, 24% of those with mild pain, 45% of those with moderate pain, and 67% of those with severe pain. More specifically, for those with severe pain, 41% filled an OP within 7 days of assessment for pain, and 26% had an OP from the 30 days before assessment for pain, leaving 33% without an OP. In multivariable analysis, factors associated with OPs are younger age, male sex, comorbid illness, cancer type, and assessment at home. CONCLUSION: Despite a generous time window for capturing OPs, the proportion of patients without an OP seems high. Further knowledge translation is required to maximize the impact of the symptom screening initiative in Ontario and to optimize management of cancer-related pain.

Health system characteristics of quality care delivery: a comparative case study examination of palliative care for cancer patients in four regions in Ontario, Canada.

BACKGROUND: A number of palliative care delivery models have been proposed to address the structural and process gaps in this care. However, the specific elements required to form competent systems are often vaguely described. AIM: The purpose of this study was to explore whether a set of modifiable health system factors could be identified that are associated with population palliative care outcomes, including less acute care use and more home deaths. DESIGN: A comparative case study evaluation was conducted of 'palliative care' in four health regions in Ontario, Canada. Regions were selected as exemplars of high and low acute care utilization patterns, representing both urban and rural settings. A theory-based approach to data collection was taken using the System Competency Model, comprised of structural features known to be essential indicators of palliative care system performance. Key informants in each region completed study instruments. Data were summarized using qualitative techniques and an exploratory factor pattern analysis was completed. RESULTS: 43 participants (10+ from each region) were recruited, representing clinical and administrative perspectives. Pattern analysis revealed six factors that discriminated between regions: overall palliative care planning and needs assessment; a common chart; standardized patient assessments; 24/7 palliative care team access; advanced practice nursing presence; and designated roles for the provision of palliative care services. CONCLUSIONS: The four palliative care regional 'systems' examined using our model were found to be in different stages of development. This research further informs health system planners on important features to incorporate into evolving palliative care systems.

Resource use and costs of end-of-Life/palliative care: Ontario adult cancer patients dying during 2002 and 2003.

The objective of this study is to estimate the direct medical cost of end-of-life and palliative (EOL/PAL) care for cancer patients during the last six months of their lives--or, during the period from diagnosis to death, if briefer--in 2002 and 2003, in Ontario, Canada. A linkage of cancer registry and administrative data is used to determine the costs of health care resources used during the EOL/PAL care period. Costs are analyzed by cancer diagnosis, location of death, and type of service. The total Ontario Ministry of Health-funded cost of EOL/PAL care for cancer patients is estimated to be about CAD$544 million per year, with an average per patient cost of about $25,000 in 2002-2003. Our results suggest that acute care consumes 75 percent of EOL/PAL funding and that only a small proportion of health care services used by EOL/PAL care cancer patients is likely to be formal palliative care.

The impact of specialized oncology nursing on patient supportive care outcomes.

Meeting the supportive care needs of cancer patients remains a challenge to cancer care systems around the world. Despite significant improvements in the organization of medical care of patients with cancer, numerous surveys of cancer populations demonstrate that significant proportions of patients fail to have their supportive care needs met. One possible solution is the introduction of a care coordinator role using oncology nursing to help ensure that patients' physical, psychological, and social support needs are addressed. Although having face validity, there is little empirical evidence on the effects of nurse-led supportive care coordinator roles on patient reported supportive care outcomes. In this article the authors present the results of a prospective longitudinal cohort study of 113 patients referred to a community-based specialist oncology nursing program. Using validated instruments they found significant improvements in patient-reported outcomes in key supportive care domains: unmet needs, quality of life, and continuity of care, as well as a shift in patterns of health resource utilization from acute care settings to the community over the course of the intervention. The results of this study are important in supporting the design and development of controlled trials to examine provider roles in the coordination of supportive cancer care.