To study the impact of different adherence levels to the enhanced recovery after surgery (ERAS) protocol and the effect of various ERAS elements on outcomes following major surgery.
Single-center prospective cohort study before and after reinforcement of an ERAS protocol. Comparisons were made both between and across periods using multivariate logistic regression. All clinical data (114 variables) were prospectively recorded.
Ersta Hospital, Stockholm, Sweden.
Nine hundred fifty-three consecutive patients with colorectal cancer: 464 patients treated in 2002 to 2004 and 489 in 2005 to 2007.
The association between improved adherence to the ERAS protocol and the incidence of postoperative symptoms, complications, and length of stay following major colorectal cancer surgery was analyzed.
Following an overall increase in preoperative and perioperative adherence to the ERAS protocol from 43.3% in 2002 to 2004 to 70.6% in 2005 to 2007, both postoperative complications (odds ratio, 0.73; 95% confidence interval, 0.55-0.98) and symptoms (odds ratio, 0.53; 95% confidence interval, 0.40-0.70) declined significantly. Restriction of intravenous fluid and use of a preoperative carbohydrate drink were major independent predictors. Across periods, the proportion of adverse postoperative outcomes (30-day morbidity, symptoms, and readmissions) was significantly reduced with increasing adherence to the ERAS protocol (>70%, >80%, and >90%) compared with low ERAS adherence (
We examined administrative outcomes after opening an oncology acute palliative care unit (APCU), to determine attainment of administrative targets related to the unit's function of acute palliation.
We retrospectively reviewed the administrative database for our APCU for the 5 years following its opening in 2003. Data were abstracted on demographic information, as well as source of admission, primary reason for admission, discharge destination, inpatient death rate, and length of stay. Linear regression and the Cochran-Armitage trend test were used for analysis. In keeping with targets set at the unit's opening, our primary hypotheses were that outpatient admissions, admissions for symptom control, and discharges home would increase over the study period; secondary hypotheses were that length of stay and inpatient death rate would decrease.
There were 1748 admissions during the study period: the median age was 64, 54% were women, and the most common cancer sites were gastrointestinal (24%), lung (20%), and gynecologic (13%). There were significant changes for all primary endpoints: outpatient admissions increased from 47% to 70% (p
Survivors of squamous cell carcinoma of the head and neck (HNSCC) are more severely affected in regard to affiliation to the work market than other cancer survivors. Few studies have investigated associations between socioeconomic and disease-related factors and work market affiliation after curative treatment of HNSCC. We investigated the factors for early retirement pension due to disability and unemployment in patients who had been available for work one year before diagnosis.
In a nationwide, population-based cohort study, data on 2436 HNSCC patients treated curatively in 1992-2008 were obtained from the Danish Head and Neck Cancer Group database and linked to Danish administrative population-based registries to obtain demographic and socioeconomic variables. We used multivariate logistic regression models to assess associations between socioeconomic factors (education, income and cohabitating status), cancer-specific variables such as tumour site and stage, comorbidity, early retirement pension and unemployment, with adjustment for age, gender and year of diagnosis.
Short education [odds ratio (OR) 4.8; 95% confidence interval (CI) 2.2-10.4], low income (OR 3.2; 95% CI 1.8-5.8), living alone (OR 3.0; 95% CI 2.1-4.4) and having a Charlson comorbidity index score of 3 or more (OR 5.9; 95% CI 3.1-11) were significantly associated with early retirement overall and in all site groups. For the subgroup of patients who were employed before diagnosis, the risk pattern was similar. Tumour stage was not associated with early retirement or unemployment.
Cancer-related factors were less strongly associated with early retirement and unemployment than socioeconomic factors and comorbidity. Clinicians treating HNSCC patients should be aware of the socioeconomic factors related to work market affiliation in order to provide more intensive social support or targeted rehabilitation for this patient group.
Despite an increasing focus on cancer rehabilitation programs, there is limited knowledge about the experiences of residential rehabilitation focusing on both the patients and their relatives.
The aim of this study was to explore the experienced benefits of the joint involvement of patients and their relatives in a 5-day residential cancer rehabilitation course, provided as part of a larger intervention study in Denmark.
Ethnographic fieldwork, consisting of participant observations and informal conversations, was conducted with 20 individuals (10 patients and 10 relatives). In-depth interviews were conducted in the participants' homes 1 month after the rehabilitation course. Data were analyzed by a constant comparative method.
Residential rehabilitation course was identified to serve as an "arena for sharing," underpinned by 3 dimensions of sharing: sharing cancer experiences, sharing strategies, and sharing mutual care.
Sharing in residential rehabilitation is experienced as useful for cancer patients and their relatives, to validate cancer-related strategies and strengthen mutual understanding within relationships.
The results can guide the development of cancer rehabilitation to involve patients and their relatives and provide opportunity for sharing and empowerment on individual as well as couple and group levels.
The number of cancer survivors is growing and cancer is now viewed as a chronic disease. This has highlighted the importance of providing adequate rehabilitation to prevent physical, psychological, and social sequelae of cancer. However, it is unclear whether those in need of rehabilitation are offered this.
Using patient-observer agreement and cognitive interviews, we validated a seven-item questionnaire designed to assess cancer patients' perception of the sufficiency of the offered rehabilitation. A cross-sectional study among 2,202 Danish cancer patients affiliated with hospitals was carried out.
The questionnaire was well understood, indicating good validity. In the cross-sectional study, 1,490 patients (68%) participated. Up to 39% of cancer patients did not receive the physical rehabilitation they felt they needed. About half of those who had felt a need to talk to a psychologist were offered this. Insufficiency of other rehabilitation offers was reported by 10-24%. Age most consistently predicted insufficient rehabilitation; higher age predicted insufficient information about support from other sources (than hospital staff) and younger age predicted lack of help to manage symptoms, return to everyday life, and deal with financial and especially work-related consequences. We found no consistent signs of traditional social inequality in the perception of rehabilitation, but we observed some signs of social inequality for unemployed or divorced/separated patients.
Age predicted sufficiency of the rehabilitation in two directions, possibly reflecting different needs in younger and older patients. When tailoring rehabilitation programs, it should be ensured that the different needs are met.
Background Systematic assessments of cancer patients' rehabilitation needs are a prerequisite for devising appropriate survivorship programs. Little is known about the fit between needs assessment outlined in national rehabilitation policies and clinical practice. This study aimed to explore clinical practices related to identification and documentation of rehabilitation needs among patients with colorectal cancer at Danish hospitals. Material and methods A retrospective clinical audit was conducted utilizing data from patient files randomly selected at surgical and oncology hospital departments treating colorectal cancer patients. Forty patients were included, 10 from each department. Semi-structured interviews were carried out among clinical nurse specialists. Audit data was analyzed using descriptive statistics, qualitative data using thematic analysis. Results Documentation of physical, psychological and social rehabilitation needs initially and at end of treatment was evident in 10% (n?=?2) of surgical patient trajectories and 35% (n?=?7) of oncology trajectories. Physical rehabilitation needs were documented among 90% (n?=?36) of all patients. Referral to municipal rehabilitation services was documented among 5% (n?=?2) of all patients. Assessments at surgical departments were shaped by the inherent continuous assessment of rehabilitation needs within standardized fast-track colorectal cancer surgery. In contrast, the implementation of locally developed assessment tools inspired by the distress thermometer (DT) in oncology departments was challenged by a lack of competencies and funding, impeding integration of data into patient files. Conclusion Consensus must be reached on how to ensure more systematic, comprehensive assessments of rehabilitation needs throughout clinical cancer care. Fast-track surgery ensures systematic documentation of physical needs, but the lack of inclusion of data collected by the DT in oncological departments questions the efficacy of assessment tools and points to a need for distinguishing between surgical and oncological settings in national rehabilitation policies.
Studies of cancer survivors' rehabilitation needs have mostly addressed specific areas of needs, e.g. physical aspects and/or rehabilitation needs in relation to specific cancer types.
To assess cancer survivors' perceived need for physical and psychosocial rehabilitation, whether these needs have been presented to and discussed with their GP.
A survey among a cohort of cancer survivors approximately 15 months after diagnosis. The questionnaire consisted of an ad hoc questionnaire on rehabilitation needs and the two validated questionnaires, the SF-12 and the Research and Treatment of Cancer quality of life questionnaire, the QLQ C-30 version 3.
Among 534 eligible patients, we received 353 (66.1%) answers. Two-thirds of the cancer survivors had discussed physical rehabilitation needs with their GPs. Many (51%) feared cancer relapse, but they rarely presented this fear to the GP or the hospital staff. The same applied to social problems and problems within the family. Good physical and mental condition and low confidence in the GP were associated with no contact to the GP after hospital discharge.
Cancer survivors have many psychosocial rehabilitation needs and intervention should effectively target these needs. If this task is assigned to the GPs, they need to be proactive when assessing psychosocial aspects.
Quality of Life (QOL) questionnaires contain two different types of items. Some items, such as assessments of symptoms of disease, may be called causal indicators because the occurrence of these symptoms can cause a change in QOL. A severe state of even a single symptom may suffice to cause impairment of QOL, although a poor QOL need not necessarily imply that a patient suffers from all the symptoms. Other items, for example anxiety and depression, can be regarded as effect indicators which reflect the level of QOL. These indicators usually have a more uniform relationship with QOL, and therefore a patient with poor QOL is likely to have low scores on all effect indicators. In extreme cases it may seem intuitively obvious which items are causal and which are effect indicators, but often it is less clear. We propose a model which includes these two types of indicators and show that they behave in markedly different ways. Formal quantitative methods are developed for distinguishing them. We also discuss the impact of this distinction upon instrument validation and the design and analysis of summary subscales.
The effect of interventions that support rehabilitation among cancer patients has to be tested before implementation.
A randomised controlled trial was conducted to test the hypothesis that a multimodal intervention may give the general practitioner (GP) an enhanced role and improve rehabilitation for cancer patients. The intervention included an interview about rehabilitation needs with a rehabilitation coordinator (RC), information from the hospital to the general practitioner about individual needs for rehabilitation and an incentive for the GP to contact the patient about rehabilitation. The objective of this first report from the study was to examine the acceptability and feasibility of the intervention.
Adult patients treated for incident cancer at Vejle Hospital, Denmark were included between May 12, 2008 and February 28, 2009. All general practices in Denmark were randomised. Patients were allocated to intervention or control (usual procedures) based on the randomisation status of their GP. The feasibility of the intervention was analysed with regard to recruitment of patients, acceptability by patients and GPs and the degree to which the planned contacts between patients, RCs and GPs were implemented. The primary outcome of the randomised controlled trial (RCT) will be health-related quality of life at six months (EORTC-30).
Following assessment of 1 896 cancer patients, 955 patients (50%) registered with 323 general practices were included. The interview was conducted at the hospital with 50% of the patients in the intervention group, 31% were contacted by phone. Patients valued the fact that the conversation was dedicated to needs beyond the medical treatment. The GPs were generally available for information by phone and positive towards having a central role in the cancer rehabilitation.
It was feasible to conduct a RCT to evaluate a complex intervention in the healthcare system. All elements of the intervention were acceptable and feasible and may be implemented in future practice if the effect is positive.