Diagnostic concordance among pathologists interpreting breast core biopsies on secondary review over a 1-year period at an Australian tertiary hospital.

This study provides data on the diagnostic concordance between initial and review diagnoses of all breast core biopsy cases at a single tertiary hospital in Western Australia over a 1-year period. A retrospective review of all breast core biopsy cases between January 1 and December 31, 2016, was carried out at PathWest, Fiona Stanley Hospital in Perth, Western Australia. Each biopsy is reported by a single pathologist and then reviewed within 1 week by a panel of intradepartmental subspecialist breast pathologists, who either agree with the original diagnosis, have a minor discordant diagnosis, or a major discordant diagnosis. Records for 2036 core biopsies were available between January 1 and December 31, 2016. Of these, 56.0% (n = 1141) were classified as benign, 34.3% (n = 699) as malignant, 7.2% (n = 147) as indeterminate, 2.3% (n = 46) as nondiagnostic, and 0.1% (n = 3) as suspicious for malignancy. In 99.1% (n = 2018) of cases, there was agreement between initial and review diagnoses. In total, 0.9% (n = 18) were disagreements: 0.49% (n = 10) were major discordant disagreements and 0.39% (n = 8) were minor discordant disagreements. All cases of major discordant disagreements would have resulted in significant changes to clinical management. This study demonstrates that an Australian institution is providing a high-quality pathology service with a low error rate between initial and review diagnoses of breast core biopsies. It reinforces the importance of secondary review of biopsies in a timely fashion for detecting potentially serious misdiagnoses that could lead to inappropriate management.

A cross-sectional analysis of out-of-pocket expenses for people living with a cancer in rural and outer metropolitan Western Australia.

Objective To determine the extent of medical and non-medical out-of-pocket expenses (OOPE) among regional/rural and outer metropolitan Western Australian patients diagnosed with cancer, and the factors associated with higher costs. Methods Cross-sectional data were collected from adult patients living in four regional/rural areas and two outer metropolitan regions in Western Australia who had been diagnosed with breast, prostate, colorectal or lung cancer. Consenting participants were mailed demographic and financial questionnaires, and requested to report all OOPE related to their cancer treatment. Results The median total OOPE reported by 308 regional/rural participants and 119 outer metropolitan participants were A$1518 (interquartile range (IQR): A$581-A$3769) and A$2855 (IQR: A$958-A$7142) respectively. Participants most likely to experience higher total OOPE were younger than 65 years of age, male, resided in the outer metropolitan area, worked prior to diagnosis, had private health insurance, were in a relationship, and underwent surgery. Multivariate analysis of regional/rural participants revealed that receiving care at a rural cancer centre was associated with significantly lower non-medical OOPE (estimated mean A$805, 95% confidence interval (CI): A$735-A$875, P=0.038; compared with other rural participants (A$1347, 95% CI: A$743-A$1951, P<0.001)). Conclusion The cancer patients who participated in this study experienced variation in OOPE, with outer metropolitan participants reporting higher OOPE compared with their regional/rural counterparts. There is a need for cost transparency and access to care close to home, so that patients can make informed choices about where to receive their care. What is known about the topic? In recent years, OOPE for health care in general and cancer in particular have been widely debated by consumers and not-for-profit organisations; the topic has attracted much political attention because it affects both equity and access to care and has wider financial implications for the community. Research studies and reports from both consumer organisations and a Ministerial Advisory Committee found that cancer patients can face exorbitant out-of-pocket costs, and that individuals with private health insurance and those with prostate and breast cancer reported higher costs. In Western Australia, a cancer centre providing comprehensive cancer care was established in the second most populous region to ameliorate the high costs for travel and accommodation that regional cancer patients are known to experience. What does this paper add? This study is unique because it collected detailed cost information from patients and reports on the OOPE of regional/rural and outer metropolitan Western Australian patients receiving care for one of the four most common cancers; it therefore offers novel insight into the experiences of these groups. This study demonstrates that outer metropolitan cancer patients are experiencing much higher OOPE compared with regional/rural cancer patients. Additionally, regional/rural study participants who accessed a Regional Cancer Centre experienced significantly lower non-medical OOPE, compared with regional/rural study participants receiving care elsewhere. What are the implications for practitioners? First, there is a need for improved communication of OOPE to minimise costs to the patient, for example, by facilitating access to local cancer care. Health service providers and insurance companies can improve cost transparency for cancer patients by making this information more readily available, allowing patients to make informed financial choices about where to seek care. Second, the needs of working patients deserve specific attention. These patients face significant work uncertainty and additional distress following a cancer diagnosis.

' If I don't have that sort of money again, what happens?': adapting a qualitative model to conceptualise the consequences of out-of-pocket expenses for cancer patients in mixed health systems.

Objective The aim of this study was to explore Western Australian cancer patients' experiences of out-of-pocket expenses (OOPE) during diagnosis and cancer treatment using a phenomenological approach. Methods Semi-structured interviews were conducted with a purposive convenience sample of 40 Western Australian cancer patients diagnosed with breast, lung, prostate or colorectal cancer. Participants were asked about the impact of their diagnosis, the associated costs and their experience within the health system. Data were analysed using thematic content analysis. Results Three key themes influencing participant OOPE experiences were identified: (1) personal circumstances; (2) communication with health providers; and (3) coping strategies. Despite Australia's public healthcare system, several participants found the costs affected their financial security and resorted to coping strategies including medication rationing and restrictive household budgeting. The key themes had a complex and interrelated effect on patient OOPE experiences and were used to adapt Carrera et al.'s model of economic consequences of cancer treatment on the patient and patient coping to describe these relationships in a mixed healthcare system. Conclusion Organised efforts must be implemented to mitigate maladaptive coping strategies being used by cancer patients: (1) health providers should seek informed financial consent from patients before commencing treatment; and (2) financial aid and support schemes for cancer patients should be reviewed to ensure they are delivered equitably. What is known on this topic? The financial cost of cancer can have significant adverse effects on cancer patients. Although financial transparency is desired by cancer patients, its implementation in practice is not clear. What does this paper add? This study adapts a conceptual model for the economic consequences of a cancer diagnosis and repurposes it for a mixed public-private health system, providing a framework for understanding downstream consequences of cancer costs and highlighting opportunities for intervention. What are the implications for health practitioners? Health practitioners need to initiate discussions concerning treatment costs earlier with cancer patients. There are several resources and guides available to assist and facilitate financial transparency. Without urgent attention to the financial consequences of cancer treatment and related expenses, we continue to leave patients at risk of resorting to maladaptive coping strategies, such as medication rationing and restrictive household budgeting.

How communication between cancer patients and their specialists affect the quality and cost of cancer care.

PURPOSE: Communication in cancer care is multidimensional and may affect patient treatment decision-making and quality of life. This study examined cancer patients' perceptions of the communication with their cancer specialists and explored its impact on the care they received and the financial burden they experienced. METHODS: Semi-structured telephone interviews were conducted with 20 rural and 20 outer metropolitan Western Australians diagnosed with breast, lung, prostate or colorectal cancer. Thematic analysis using a phenomenological approach was undertaken to derive key themes regarding the communication experiences of the participants. RESULTS: Four main themes emerged: information context, communication about treatment options and treatment providers, communication about costs of treatment and impact of communication on continuity of care. The quality of the communication experienced by participants was variable and in many cases sub-optimal. This affected their ability to undertake well-informed decisions regarding treatment and providers and led to substantial out-of-pocket expenses for several participants. Whilst participants differed in their information needs and expectations, most participants trusted clinicians' treatment recommendations. CONCLUSIONS: Our results raise concerns about the quality of communication cancer patients receive during treatment and the repercussions for their treatment decisions and out-of-pocket expenses. Clear treatment and cost communication could empower patients in choosing treatment and providers. However, these findings suggest patients must remain vigilant during consultations and discuss available treatment pathways and their financial dimension to avoid costly treatments or missing out on available financial aid.

Out-of-pocket expenses experienced by rural Western Australians diagnosed with cancer.

PURPOSE: Out-of-pocket expenses (OOPE) can have a significant impact on patients' experiences of cancer treatment. This cross-sectional study sought to quantify the OOPEs experienced by rural cancer patients in Western Australia (WA), and determine factors that contributed to higher OOPE. METHODS: Four hundred people diagnosed with breast, lung, colorectal or prostate cancer who resided in selected rural regions of WA were recruited through the WA Cancer Registry and contacted at least 3 months after diagnosis to report the medical OOPE (such as surgery or chemotherapy, supportive care, medication and tests) and non-medical OOPE (such as travel costs, new clothing and utilities) they had experienced as a result of accessing and receiving treatment. Bootstrapped t tests identified demographic, financial and treatment-related factors to include in multivariate analysis, performed using log-linked generalised linear models with gamma distribution. RESULTS: After a median 21 weeks post-diagnosis, participants experienced an average OOPE of AU$2179 (bootstrapped 95% confidence interval $1873-$2518), and 45 (11%) spent more than 10% of their household income on these expenses. Participants likely to experience higher total OOPE were younger than 65 years (p = 0.008), resided outside the South West region (p = 0.007) and had private health insurance (PHI) (p < 0.001). CONCLUSIONS: Rural WA cancer patients experience significant OOPE following their diagnosis. The impact these expenses have on patient wellbeing and their treatment decisions need to be further explored.

Admissions for antibiotic-resistant infections in cancer patients during first year of cancer diagnosis: a cross-sectional study.

In this study, linked Western Australian health data were used to determine presence of an antibiotic-resistant infection (ABRI) for all people diagnosed with a primary invasive cancer in 2009. Of 10 858 cancer cases, 154 (1.42%) had an ABRI. Patients with an ABRI were older (71.5 vs 66 years), and more had died in the year following diagnosis (37.7 vs 20.2%, P < 0.001). The ABRI cohort had a higher proportion of colorectal, genitourinary and haematological cancers (19.5 vs 11.9%; 14.3 vs 9.7% and 16.9 vs 5.8%, respectively). Hospital admissions with an ABRI were longer (22.3 vs 2.9 days, P < 0.001) and had a higher proportion of unplanned admissions (60.3 vs 15.2%), admissions through emergency department (36.8 vs 8.3%) and intensive care admissions (14.9 vs 1.7%, P < 0.001). Patients with solid tumours who developed an ABRI were more likely to have received chemotherapy (35.9 vs 27.8%, P = 0.04). In haematological cancer patients, a greater proportion of the admissions with an ABRI occurred after radiation therapy or chemotherapy (P = 0.01 and P = 0.005, respectively). This study is the first to report population-level data on ABRI in cancer patients. Patients with an ABRI had more hospital admissions and poorer outcomes.

Knowledge translation lessons from an audit of Aboriginal Australians with acute coronary syndrome presenting to a regional hospital.

OBJECTIVE: Translation of evidence into practice by health systems can be slow and incomplete and may disproportionately impact disadvantaged populations. Coronary heart disease is the leading cause of death among Aboriginal Australians. Timely access to effective medical care for acute coronary syndrome substantially improves survival. A quality-of-care audit conducted at a regional Western Australian hospital in 2011-2012 compared the Emergency Department management of Aboriginal and non-Aboriginal acute coronary syndrome patients. This audit is used as a case study of translating knowledge processes in order to identify the factors that support equity-oriented knowledge translation. METHODS: In-depth interviews were conducted with a purposive sample of the audit team and further key stakeholders with interest/experience in knowledge translation in the context of Aboriginal health. Interviews were analysed for alignment of the knowledge translation process with the thematic steps outlined in Tugwell's cascade for equity-oriented knowledge translation framework. RESULTS: In preparing the audit, groundwork helped shape management support to ensure receptivity to targeting Aboriginal cardiovascular outcomes. Reporting of audit findings and resulting advocacy were undertaken by the audit team with awareness of the institutional hierarchy, appropriate timing, personal relationships and recognising the importance of tailoring messages to specific audiences. These strategies were also acknowledged as important in the key stakeholder interviews. A follow-up audit documented a general improvement in treatment guideline adherence and a reduction in treatment inequalities for Aboriginal presentations. CONCLUSION: As well as identifying outcomes such as practice changes, a useful evaluation increases understanding of why and how an intervention worked. Case studies such as this enrich our understanding of the complex human factors, including individual attributes, experiences and relationships and systemic factors that shape equity-oriented knowledge translation. Given the potential that improving knowledge translation has to close the gap in Aboriginal health disparities, we must choose strategies that adequately take into account the unique contingencies of context across institutions and cultures.