Organization of the clinical activity of geriatric oncology: report of a SIOG (International Society of Geriatric Oncology) task force.

Management for elderly cancer patients world wide is far from being optimal and few older patients are entering clinical trials. A SIOG Task Force was therefore activated to analyze how the clinical activity of Geriatric Oncology is organized. A structured questionnaire was circulated among the SIOG Members. Fifty eight answers were received. All respondents identified Geriatric Oncology, as an area of specialization, however the organization of the clinical activity was variable. Comprehensive Geriatric Assessment (CGA) was performed in 60% of cases. A Geriatric Oncology Program (GOP) was identified in 21 centers, 85% located in Oncology and 15% in Geriatric Departments. In the majority of GOP scheduled case discussion conferences dedicated to elderly cancer patients took regular place, the composition of the multidisciplinary team involved in the GOP activity included Medical Oncologists, Geriatricians, Nurses, Pharmacists, Social Workers. Fellowships in Geriatric Oncology were present in almost half of GOPs. Over 60% of respondents were willing to recruit patients over 70 years in clinical trials, while the proportion of cases included was only 20%. Enrolment in clinical trials was perceived as more difficult by 52% and much more difficult in 12% of the respondents. In conclusion, a better organization of the clinical activity in Geriatric Oncology allows a better clinical practice and an optimal clinical research. The GOP which can be set up in the oncological as well as in the geriatric environment thought a multidisciplinary coordinator effort. Future plans should also concentrate on divisions, units or departments of Geriatric Oncology.

Hospital Outcomes Project for the Elderly (HOPE): rationale and design for a prospective pooled analysis.

OBJECTIVE: To describe a collaborative investigation that is based on a series of six clinical studies aimed at reducing functional decline in the acutely-ill hospitalized elderly. DESIGN: A prospective, multicenter pooled analysis project involving collection of a common set of data from a group of related but distinct intervention trials with similar objectives. SETTING: Five university-affiliated hospitals and one community hospital. PARTICIPANTS: Elderly patients (age minimums from 65 to 75 years) admitted for a range of acute illnesses. INTERVENTIONS: Site-specific interventions include exercise and physical therapy; developing and implementing methods to improve detection and evaluation of delirious patients; a multidisciplinary geriatric care unit; a multidisciplinary intervention implemented in-hospital that includes some post-discharge care; and a nursing-centered geriatric care program. MAIN OUTCOME MEASURE: Functional status. CONCLUSION: The prospective, multicenter design of the Hospital Outcomes Project for the Elderly (HOPE) provides an innovative approach for analysis of hospital outcomes in the elderly. Although differences in study populations and interventions exist, qualitative comparisons across sites will enhance generalizability and will provide a great opportunity to examine consistency among the sites. The HOPE pooled analysis project will impart greater statistical power to detect the primary and secondary outcomes compared with previous single-center trials that have assessed interventions related to functional decline in the hospitalized elderly.

Quality of care during a community-wide experiment in prospective payment to hospitals.

To determine whether a community-wide experiment in hospital prospective payment adversely affected quality of care, availability and outcomes of care were studied in Rochester, NY from 1980 to 1984. During this 5-year period, prospective payment contained hospital expenditures in a community that was already below the national average in health-care costs. Access to necessary care was maintained, and there were increased admissions for management of maternal illness and acute myocardial infarction. Rates of inpatient elective surgery declined. Outcomes of care remained stable, including neonatal deaths, ischemic heart disease deaths, deaths from five selected surgical conditions, and rates of adverse outcomes from sentinel medical and surgical conditions. These results indicated that prospective payment programs in which incentives to decrease marginal or unneeded care are linked with a community-wide effort to plan for the delivery of services can be financially and clinically successful.

A community hospital payment experiment outperforms national experience. The Hospital Experimental Payment program in Rochester, NY.

Since January 1980, the hospitals in the Rochester, NY, area have been operating under a community-wide revenue cap. This prospective payment system features local administration and control and is the first time a group of hospitals have committed themselves to a comprehensive regional financing system. This system differs from other prospective payment programs in that it covers both inpatient and outpatient care and offers incentives for ambulatory treatment whenever clinically appropriate. In the first five years of this program, the increase in Rochester area hospital expenses was 46%, compared with 52% for New York State hospitals and 68% for US hospitals at large. Further, the financial position of the Rochester hospitals improved, showing an operating margin of 2.6%, compared with a figure of-15.8% for New York State hospitals at large. A community-wide assessment showed no evidence of a reduction in the quality of or access to care. This community system for hospital payment and planning merits serious consideration for areas wishing to realize high-quality care at an affordable cost through a balanced combination of self-regulation, cooperation, and competition.

An ambulatory training model for an obstetrics and gynecology residency program.

An important educational objective of an obstetric-gynecologic residency program is to provide an ambulatory experience from which residents can develop attitudes and skills that will enable them to provide high-quality comprehensive care to their patients. Often traditional outpatient clinics hold second-class positions in a training program, with surgical or obstetrical procedures being more highly valued experiences. From the patients' point of view many of these clinics are uncomfortable, noisy, and unattractive; and the patients in many instances receive depersonalized, discontinuous care. There is, therefore, a pressing need to implement efficient strategies to meet the increasing community demands for outpatient services while at the same time providing an innovative and effective ambulatory experience for residents. This paper describes how in a cooperative effort between a hospital's Department of Ambulatory Services and Department of Obstetrics and Gynecology these educational objectives were successfully integrated with those of continuous and comprehensive patient care.