Electronic prescribing systems as tools to improve patient care: a learning health systems approach to increase guideline concordant prescribing for venous thromboembolism prevention.

BACKGROUND: Venous thromboembolism (VTE) causes significant mortality and morbidity in hospitalised patients. Risk factors for VTE are well known and there are validated risk assessment tools to support the use of prophylactic therapies. In England, reporting the percentage of patients with a completed VTE risk assessment is mandated, but this does not include whether that risk assessment resulted in appropriate prescribing. Full guideline compliance, defined as an assessment which led to an appropriate action-here prescribing prophylactic low molecular weight heparin where indicated, is rarely reported. Education, audit and feedback enhance guideline compliance but electronic prescribing systems (EPS) can mandate guideline-compliant actions. We hypothesised that a systems-based EPS intervention (prescribing rules which mandate approval or rejection of a proposed prescription of prophylactic low molecular weight heparin based on the mandated VTE assessment) would increase full VTE guideline compliance more than interventions which focused on targeting individual prescribers. METHODS: All admitted patients within University Hospitals Birmingham NHS Foundation Trust were included for analysis between 2011 and 2020. The proportion of patients who received a fully compliant risk assessment and action was assessed over time. Interventions included teaching sessions and face-to-face feedback based on measured performance (an approach targeting individual prescribers) and mandatory risk assessment and prescribing rules into an EPS (a systems approach). RESULTS: Data from all 235,005 admissions and all 5503 prescribers were included in the analysis. Risk assessments were completed in > 90-95% of all patients at all times, but full guideline compliance was lower (70% at the start of this study). Face-to-face feedback improved full VTE guideline compliance from 70 to 77% (p ≤ 0.001). Changes to the EPS to mandate assessment with prescribing rules increased full VTE compliance to 95% (p ≤ 0.001). Further amendments to the EPS system to reduce erroneous VTE assessments slightly reduced full compliance to 92% (p < 0.001), but this was then maintained including during changes to the low molecular weight heparin used for VTE prophylaxis. DISCUSSION: An EPS-systems approach was more effective in improving sustained guideline-compliant VTE prevention over time. Non-compliance remained at 8-5% despite this mandated system. Further research is needed to assess the potential reasons for this.

Survival with retinoblastoma in the USA: 1975-2004.

BACKGROUND: The purpose of this study was to determine the survival of retinoblastoma in the USA over a 30-year period from 1975 to 2004 using a systematic review of existing databases. METHODS: Nine hundred and ninety-two cases of retinoblastoma (International Classification of Oncology (ICDO-3) codes C69.2 (retina) and C69.9 (eye, NOS)) were derived from the Surveillance, Epidemiology and End Results (SEER) program database in the USA from 1975 to 2004. All 17 current SEER registries were utilised to allow for optimal patient volume for statistical analysis. Survival rates were calculated by the Kaplan-Meier method and differences evaluated with logrank and Wilcoxon tests. Cause of death was obtained and reviewed for all deceased patients. All retinoblastoma patient records were reviewed for treatments given and occurrence of second malignant neoplasms. RESULTS: There were a total of 990 distinct patients with retinoblastoma. Almost all cases (99.1%) were reported by the hospitals, and histopathological confirmation was available in 87.7% of cases. Over the period of 30 years (1975-2004), the 5-year observed actuarial survival rate increased from 92.3% (1975-84) to 93.9% (1985-94) to 96.5% (1995-2004). The difference in rates was statistically significant (Wilcoxon = 6.2393, p = 0.0442). The proportion of cases treated with radiotherapy first increased from 20.5% in 1975-9 to 34.6% in 1985-9 and then sharply decreased to 6.5% in 2000-4. CONCLUSIONS: Over the last 30 years, there has been a gradual improvement in 5-year survival of children with retinoblastoma in the USA.

Incidence of retinoblastoma in the USA: 1975-2004.

BACKGROUND: The purpose of this study was to determine the age-adjusted incidence of retinoblastoma in the USA over a 30-year period from 1975 to 2004 using a review of existing databases. METHODS: Six hundred and fifty-eight patients with retinoblastoma (International Classification of Oncology (ICDO-3) codes C69.2 (retina) and C69.9 (eye, NOS)) were derived from the Surveillance, Epidemiology, and End Results (SEER) program database in the USA from 1975 to 2004. Nine historical SEER registries were utilised. The significance of trend in age-adjusted incidence rate was determined using the chi(2) test, and 95% CIs were calculated. The patients were stratified according to age at diagnosis, laterality, gender and race. RESULTS: There were a total of 658 cases of retinoblastoma, representing 6.1% of all childhood cancers under age 5 years. The mean age-adjusted incidence of retinoblastoma in the USA was 11.8 per million children aged 0-4 years (95% CI 10.9 to 12.8). There was no significant trend in age-adjusted incidence for all races/genders, nor was there any significant variation of incidence between races or between genders. The proportion of bilateral cases (26.7%) versus unilateral cases (71.9%) remained stable over the 30-year period. CONCLUSIONS: The mean age-adjusted incidence rate of retinoblastoma of 11.8 cases per million children aged 0-4 years in the USA is similar to rates reported from European countries. The age-adjusted incidence rate of retinoblastoma in the USA has remained stable for the last 30 years.

Safety, effectiveness and cost efficacy of diagnostic electrophysiology and radiofrequency ablation in a district general hospital.

Electrophysiological studies (EPS) are now being performed in district general hospitals (DGH) in the UK. In order to audit our results, a prospective database was established for all patients undergoing EPS and radiofrequency (RF) ablation at Eastbourne District General Hospital, East Sussex. Between 1 January 1997 and 1 July 2000, 300 EPS procedures were performed, resulting in 155 RF ablations. The average RF ablation procedure time was 119.3 minutes with an average fluoroscopy time of 19.1 minutes. Cost per RF ablation procedure was 1166.79 Pounds excluding use of facilities, pacemaker devices, medical nursing and radiography staffing costs. The overall success rate for RF ablation was 93.6% with a major complication rate of 0.6%, a total complication rate of 3.9% and no associated mortality. We have shown that RF ablation can be performed safely, effectively and economically in a DGH setting with a high rate of success and a low complication rate.

Second malignant neoplasms in patients under 40 years of age with laryngeal cancer.

OBJECTIVES/HYPOTHESIS: To determine the incidence of second malignant neoplasms (SMN) in patients under 40 years of age with invasive squamous cell carcinoma (SCC) of the larynx. STUDY DESIGN: Retrospective. METHODS: Using a National Cancer Institute tumor registry database encompassing 1973-1996, the incidence of SMN in patients under 40 years of age with laryngeal cancer was determined and compared with that of the registry's older, more traditional laryngeal cancer population. Median follow-up was 136 months. RESULTS: Among the 364 patients under the age of 40 years with laryngeal cancer, 30 (8.2%) had developed a secondary malignancy to date. In comparison, 4876 (21.4%) of 22,786 patients 40 years or older with laryngeal cancer were affected by an SMN. Kaplan-Meier analysis of the younger cohort projected 3.0%, 6.8%, and 10.7% relative risk of developing a SMN at any site over 5-, 10-, and 15-year periods, respectively, after index tumor diagnosis. Similar results for the older cohort were 14.2%, 28.1%, and 39.4% at 5, 10, and 15 years, respectively. Further Kaplan-Meier analysis demonstrated at least a fourfold increased risk for the development of secondary upper aerodigestive tract malignancies among older compared with younger patients. CONCLUSION: Patients under 40 years of age with invasive SCC of the larynx are significantly less likely to develop a second malignancy than their older counterparts.

Node counts in neck dissection: are they useful in outcomes research?

OBJECTIVES: We studied the unilateral nodal yields for procedures reported as standard or modified radical neck dissection (RND) to determine their applicability in outcomes research. METHODS: We analyzed the unilateral nodal yields for all procedures reported as RND for carcinoma of the oral cavity, pharynx, and larynx at our institution from 1985 to 1997 (n = 64, no prior treatment). These included both standard and modified techniques, encompassing levels I through V of the neck. Each side of a bilateral RND was treated as a separate case. This sample was compared with a similar population from the National Cancer Institute's Surveillance, Epidemiology, and End-Results (SEER) registry. Nodal yield was obtained for RND alone and for unspecified neck dissection with primary excision for the same diseases and time period (n = 1499). RESULTS: The mean nodal yield from 64 RND was 30 vs 27 in the SEER data. The standard deviation was 14.7 compared with 17.2 in the SEER data. Values ranged from 7 to 66 nodes whereas the SEER range was from 1 to 97 nodes. Although the SEER data contain nodal yields from regional or selective neck dissection, we corroborate our findings of large variance in nodal yield from our RND sample. CONCLUSIONS: Large variance in nodal yields from RND may have undefined effects on quality of life, cure rate, and survival. Until correlation of nodal yields with outcomes is examined, we cannot know how to relate RND to outcomes.

Risk of colorectal cancer after breast cancer.

BACKGROUND: History of breast cancer has been reported as a risk factor for colorectal cancer in women. In view of the ambiguous nature of existing evidence and the growing interest in targeted colorectal cancer prevention, we sought to quantify this risk. METHODS: We used the Surveillance Epidemiology and End Results (SEER) database to estimate risk of colorectal cancer after breast-cancer diagnosis in women with first incident breast cancer between 1974 and 1995. Observed colon and rectal cancer risk was compared with that expected in the general population. We stratified comparisons by age at breast-cancer diagnosis, stage of cancer, ethnic origin of patient, and follow-up time. FINDINGS: Overall, women with previous breast cancer were 5% less likely (95% CI 1-9) to develop colon and 13% less likely (6-19) to develop rectal cancer than women in the general population. Stratified analyses suggested that the risk reductions observed for colon and rectal cancer were most pronounced for women with breast cancer diagnosed after age 65 years, in white women, women with local stage breast cancer, and women diagnosed in the later study years (1990-94). INTERPRETATIONS: Breast cancer does not increase subsequent colorectal cancer risk, and reduced risk was seen for certain subgroups of women. Because no biologically plausible endogenous protective factor has been identified, we suggest that reduced risk could stem from an accumulation of exposures that increase breast-cancer frequency but protect against colorectal cancer.

Thoracic reirradiation for symptomatic relief after prior radiotherapeutic management for lung cancer.

Limited information is available in the medical literature on thoracic reirradiation for patients with recurrent/persistent lung carcinoma or new primary lung tumors. Controversy exists regarding the retreatment because of concerns regarding the risk of radiation toxicity. The medical and radiotherapeutic records of more than 1,500 patients with lung cancer seen in the Department of Radiation Oncology at Thomas Jefferson University Hospital from 1982 through 1997 were searched. Twenty-three patients with history of previous thoracic radiation therapy underwent thoracic reirradiation for either biopsy-proven and/or radiographically evident tumor recurrence, metastasis, or second lung primary. Most patients were reirradiated because of progressive dyspnea, cough, thoracic pain, or hemoptysis. Each of these symptoms was evaluated separately with regard to the subjective response to reirradiation. The median follow-up time from completion of reirradiation to last correspondence with the patient and/or family was 3.2 months, with a range of 0 to 17.5 months. In six patients with hemoptysis, a decrease or resolution of this symptom was noted. Of five patients with thoracic pain attributed to carcinoma, four noted an improvement in pain after reirradiation. Of 15 patients with cough, 9 had an improvement in cough, and of 15 patients with dyspnea, 11 had an improvement. Thoracic reirradiation is an effective modality in patients with hemoptysis, thoracic pain, cough, and dyspnea attributed to a radiographically defined recurrence and/or progression of lung cancer.

Changing epidemiology of anorectal melanoma.

PURPOSE: We reviewed 117 cases of anorectal melanoma to better define epidemiologic and survival characteristics of this rare neoplasm. METHODS: The National Cancer Institute Surveillance, Epidemiology, and End Results database covering the period 1973 through 1992 was used. This represents 9.5 percent of the United States population. Melanoma arising in the anorectum was identified using International Classification of Diseases for Oncology codes. Two-tailed Student's t-test, chi-squared, and Wilcoxon's tests were used for comparisons of means, proportions, and actuarial survival rates, respectively. RESULTS: One hundred seventeen cases of anorectal melanoma were identified, representing 0.048 percent of all colorectal malignancies in the database. The male-to-female ratio was 1:1.72. The mean age was 66 +/- 16 years. Mean age by gender, however, was lower for males (57 years) then for females (71 years; P < 0.001). The age difference represents an increased incidence of anorectal melanoma in males younger than the age of 45 years. Furthermore, the incidence of anorectal melanoma in young males ages between 25 to 44 years tripled in the San Francisco area when compared with all other locations (14.4 vs. 4.8 per 10 million population; P = 0.06). Males have a survival advantage over females (62.8 percent vs. 51.4 percent 1-year and 40.6 percent vs. 27.7 percent 2-year; P < 0.01). CONCLUSIONS: The overall incidence of anorectal melanoma continues to rise and survival rates remain poor. A new trend toward bimodal age distribution was observed. There is indirect evidence that implicates human immunodeficiency virus infection as a risk factor. Survival rate is better in young patients aged 25 to 44 years.

Risk for colorectal cancer after gynecologic cancer.

BACKGROUND: Studies have suggested that women with previous diagnoses of gynecologic cancer (cervical, endometrial, or ovarian) have an increased risk for colorectal cancer. OBJECTIVE: To quantify risk for colorectal cancer after gynecologic cancer, both overall and for subgroups defined by age at diagnosis, cancer stage at diagnosis, ethnicity, and duration of follow-up. DESIGN: Retrospective cohort analysis of the Surveillance, Epidemiology, and End Results (SEER) program database from 1974 through 1995. SETTING: U.S. cancer registry. PATIENTS: 21,222 patients with cervical cancer, 51,680 patients with endometrial cancer, and 28,832 patients with ovarian cancer. MEASUREMENTS: Standardized incidence ratios (SIRs) were calculated for each gynecologic cancer site and for subgroups to represent the relative risk for colorectal cancer in women with previously diagnosed gynecologic cancer compared with women without gynecologic cancer. Poisson regression methods adjusting simultaneously for all study variables were used to estimate relative risks for colorectal cancer across subgroups with each gynecologic cancer. RESULTS: Overall, risk for colorectal cancer was elevated among women with previous ovarian cancer (SIR, 1.36 [95% CI, 1.21 to 1.53]). Risk was greatest in women who received a diagnosis before 50 years of age (SIR, 3.67 [CI, 2.74 to 4.80]) but was also elevated in women who received a diagnosis between 50 and 64 years of age (SIR, 1.52 [CI, 1.25 to 1.83]). The risk for colorectal cancer after endometrial cancer was also elevated substantially if endometrial cancer was diagnosed before the age of 50 (SIR, 3.39 [CI, 2.73 to 4.17]). No apparent risk elevation was associated with previous cervical cancer. CONCLUSIONS: Previous endometrial or ovarian cancer, particularly when diagnosed at an early age, increases subsequent risk for colorectal cancer. Greater emphasis on colorectal cancer screening in these populations may be necessary.

Adenosquamous carcinoma of the colon, rectum, and anus: epidemiology, distribution, and survival characteristics.

PURPOSE: There have been 49 cases of adenosquamous carcinoma of the colon, rectum, and anus reported in the English literature. We have reviewed 145 cases of adenosquamous carcinoma to better define epidemiologic and survival characteristics of this extremely rare colon carcinoma. METHODS: The National Cancer Institute's Surveillance, Epidemiology, and End Results program public use CD-ROM file for the years 1973 through 1992 were reviewed. This represents approximately 9.5 percent of the United States population. Adenosquamous carcinomas arising in the colon, rectum, and anus were identified using the International Classification of Diseases-O codes. The Astler-Coller tumor classification was used for staging. Two-tailed Student's t-test, Mantel-Haenszel chi-squared tests, and generalized Wilcoxon's tests were used for comparisons of means, proportions, and actuarial survival rates, respectively. Survival curves were calculated by the Kaplan-Meier method. RESULTS: One hundred forty-five cases of adenosquamous carcinoma were identified, representing 0.06 percent of all colorectal malignancies. The mean age of patients was 67 years. Eighty-four percent of patients were Caucasians, 15 percent were Afro-Americans, and 1 percent were other races. Afro-Americans were diagnosed at a significantly younger age (median age, 62 years; P = 0.03). Fifty-three percent of the carcinomas were located in the sigmoid colon, rectum, and anus, 28 percent in the right colon, and the rest in the middle segment. Seventy-four percent of distal cases were staged A through C, compared with 44 percent of proximal cases. Patients with adenosquamous carcinoma of the sigmoid colon, rectum, and anus survived longer than all other patients (P = 0.001). Patients with adenosquamous carcinoma Stages A and B1 had survival rates similar to patients with comparably staged adenocarcinomas. Fifty percent of the patients, including most of the patients with D stage, died in the first year. Patients with Stages B2, C, and D adenosquamous carcinomas had a significantly shorter survival than the comparably staged adenocarcinomas (P < or = 0.02). The overall adjusted five-year survival rate was 30.7 percent. In those patients who survived more than 24 months, the five-year survival was 84 percent. CONCLUSIONS: The survival rates for patients with adenosquamous carcinoma Stages A and B1 are similar to patients with comparably staged colorectal adenocarcinomas. However, we found that patients with colorectal and anal adenosquamous carcinomas staged B2 through D have significantly poorer survival than patients with comparably staged adenocarcinomas, supporting the previous reports of a poor prognosis associated with adenosquamous carcinomas.

Will primary central nervous system lymphoma be the most frequent brain tumor diagnosed in the year 2000?

BACKGROUND: There has been a dramatic increase in the diagnosis of primary lymphoma of the brain during the past decade, prompting speculation that it may become the most frequently diagnosed tumor of the central nervous system by the year 2000. The current analysis drew from the updated Surveillance, Epidemiology, and End Results (SEER) database to establish projections for the incidence of brain lymphoma. The study also attempted to determine whether increased incidence rates are attributable to the increasing incidence of acquired immunodeficiency syndrome (AIDS) and whether there is gender or age dependence. METHODS: Primary brain lymphoma case data and population census data for calculating incidence rates for the period 1973-1992 were obtained from the SEER program. In an attempt to determine the contribution of AIDS to the increasing incidence of the disease, separate analyses were performed with and without the inclusion of never married men (a high risk group for the development of AIDS). Separate analyses were also performed within the San Francisco SEER registry because a higher incidence of AIDS-related cancers has been documented in this geographic region. Finally, a piece-wise linear model (using one regression line until 1982 and another regression line from 1982 onward) was used to predict incidence rates for the year 2000. RESULTS: During the period of study, the incidence rates of brain lymphoma increased more than 10-fold, from 2.5 cases per 10 million population in 1973 to 30 in 1991-1992 (chi-square trend, 17.76: P < 0.0001). These increased incidence rates were independent of age and gender. The incidence rates of primary brain lymphoma did not differ significantly when comparing the San Francisco registry with the remainder of the SEER database for any comparison that excluded never married males. However, when the analysis included never married males, a statistically significantly higher incidence rate of primary central nervous system lymphoma was observed among San Franciscans compared with age-matched controls from the remainder of the SEER database. In the year 2000, the projected incidence rate of brain lymphoma would reach 51.1 per 10 million population and 118.2 per 10 million population, with never married men excluded and included, respectively. These incidence rates would still fall below the corresponding projections for glioma and glioblastoma multiforme. CONCLUSIONS: There continues to be a significantly increasing incidence of brain lymphoma that is independent of age and gender. Indirect evidence implicates the AIDS epidemic as a contributor to this trend. Although the rate of increase in the incidence of non-Hodgkin's lymphoma of the brain is higher than for peripheral non-Hodgkin's lymphoma and other glial tumors, brain lymphoma is not projected to surpass glial tumors as the most frequently diagnosed intracranial malignancy by the year 2000.

Elapsed radiation therapy treatment time as a predictor of survival in patients with advanced head and neck cancer who receive chemotherapy and radiation therapy.

PURPOSE: To determine whether elapsed radiation therapy treatment time relates to survival in patients with head and neck cancer treated sequentially with chemotherapy and radiation therapy. MATERIALS AND METHODS: From 1981 to 1988, 76 adult patients with bulky stage II-IV head and neck cancer received induction chemotherapy (fluorouracil and cisplatin). Those with a complete or partial response (n = 46) received full-dose definitive radiation therapy (range, 64.0-77.5 Gy; median, 70 Gy). Those with less than a partial response (n = 21) underwent surgery and postoperative radiation therapy (n = 15), palliative radiation therapy (n = 4), or palliative chemotherapy (n = 2). Nine patients refused to undergo radiation therapy after induction chemotherapy. RESULTS: The 5-year overall survival rates were as follows: 32% in all patients, 38% in patients who underwent chemotherapy and radiation therapy, and 27% in patients who underwent chemotherapy, surgery, and radiation therapy. The number of days between radiation therapy treatments was highly predictive of overall survival. In the groups with treatments less than 55 days apart, 56-65 days apart, and more than 66 days apart, the 5-year survival rates were 56%, 46%, and 15%, respectively (P = .02). CONCLUSION: The time between radiation therapy treatments is strongly predictive of survival in patients undergoing sequential chemotherapy and radiation therapy. The use of induction chemotherapy does not negate the need to avoid treatment interruptions during definitive radiation therapy.

Cholangiocarcinoma: clinical significance of tumor location along the extrahepatic bile duct.

PURPOSE: To define the criteria for resection and/or radiation therapy (RT) of extrahepatic bile duct cancer. MATERIALS AND METHODS: Of 81 patients with extrahepatic bile duct cancer treated from 1983 to 1992, those with proximal duct lesions (n = 56) underwent RT and/or resection or palliative care, and those with distal lesions (n = 25) underwent resection with or without RT. Follow-up was available 3-114 months (median, 28 months). RESULTS: Patients with distal bile duct cancer lived longer than patients with proximal bile duct cancer (survival with Kaplan-Meier analysis, 53% vs 13% at 5 years, respectively, P < .01). Median survival in patients with proximal cancer after RT was more than double that without RT (17 months vs 6 months, respectively, regardless of stage [P = .01]); survival was not significantly different after resection. In patients with distal cancer, RT after resection made no significant difference in median survival (68 months). CONCLUSION: Patients with proximal cancer should undergo primary RT, and expectations should be limited. Patients with distal cancer should undergo resection, and RT may not be needed.

Breast conservation following induction chemotherapy for locally advanced carcinoma of the breast (stages IIB and III). A surgical perspective.

We have now employed induction chemotherapy in almost 200 women with locally advanced breast carcinoma. Significant tumor regression has been noted in a majority of patients, 85%, permitting definitive local treatment with greater success than heretofore expected. Breast conservation has been offered to a larger proportion of these women as we have gained experience with this technique, with outcome equivalent to that of mastectomy in these highly selected patients. Our previously dismal outlook for patients with advanced local disease has been replaced by a more optimistic attitude. Our achievements with this initial group of patients and currently with stage II patients as well is most encouraging. Breast conservation has been offered to a larger proportion of these women, with outcome equivalent to mastectomy. We hope that our limited but encouraging experience with these patients will stimulate other investigators to embark upon similar studies of induction chemotherapy for women with stages II and III, and even earlier, breast cancer.

Causes of deaths--testicular cancers in Delaware, 1972-1986.

This analysis of 135 germ cell testicular cancers in a defined population within one state from 1972 through 1986 confirms the reported incidence of seminoma (52%) vs. non-seminoma with significant age differences between the two histologic types, and shows that the adjusted (real) ten year survival from disease in a community setting can be better than 90%. Earlier diagnosis should make some differences and more aggressive therapy and follow-up including restaging especially of the teratocarcinomas, might improve the end results. This is not a benign disease even in seminomas where recurrent slow growing seminomas should also be given curative chemotherapy although the current experience does not specially point to that conclusion. The ACCC is encouraged to stimulate community studies using prospectively designed check lists to allow a more complete analysis of cancers with a high cure rate in order to assure optimum community application of the results of the National clinical trials in which many are now engaged.