Abstract only
605
Background: Physician and nurse satisfaction is positively correlated with patient satisfaction. In our university centre we have established the Gastrointestinal Oncology Clinic ...Amsterdam (GIOCA), a patient centred multidisciplinary one day diagnostics and fast track treatment planning outpatient clinic for gastrointestinal malignancies. The GIOCA team consists of dedicated surgeons, gastroenterologists, medical oncologists, radiation oncologists, radiologists, nuclear radiologists, pathologists, and specialized nurses. We have measured a high patient satisfaction. However to our knowledge there are no studies that focus on the satisfaction of physicians and nurses working within a multidisciplinary team. Our aim was to evaluate the experience and work satisfaction of the physicians and nurses at GIOCA. Methods: A qualitative observational study was performed to compose a questionnaire. This questionnaire was then sent to every physician (specialist, fellow, and resident) and nurse (n=77) working at the outpatient clinic. Answers were given on a 5-point Likert scale. Data were analysed using non-parametric tests. Results: The questionnaire was answered by 73 respondents, of whom 8.2% were nurses and 91.8% were physicians (95% overall response rate). Overall satisfaction with the fast track outpatient clinic was high for all groups (4; 3-5). The workload was experienced as average by physicians and high by nurses (p<0.001). The highest emotional strain was reported by nurses and residents. The emotional strain reported by residents was significantly higher compared to the level of emotional strain reported by specialists (p=0.034). The quality of the multidisciplinary meeting was rated high by both physicians and nurses. The importance of a multidisciplinary one day diagnostics outpatient clinic was invariably rated high to very high by all physicians and nurses. Conclusions: The overall work satisfaction at GIOCA is high. A patient centred one day diagnostics and fast track treatment outpatient clinic for gastrointestinal malignancies is indispensible according to the physicians and nurses. This may have contributed to a high patient satisfaction and a high overall work satisfaction.
Abstract only
659
Background: In order to reduce long waiting times, a one-stop fast-track multidisciplinary outpatient clinic for gastrointestinal malignancies was initiated. Lean Six Sigma (LSS) is ...a combination of Lean-management and the Six Sigma methodology. LSS incorporates means to systematically identify and address suboptimal performance of a process. Lean and Six Sigma have their origin in the manufacturing industry, like the Toyota car factory, with largely homogenous products. In contrast, a complex high care oncology facility deals with heterogeneous patients. Our aim is to use the tools and strategies of LSS to increase the number of patients with an admission time (AT) of five days or less to ≥ 85% and to ensure that ≥ 90% of referring physicians receive the decisions formulated at the Multidisciplinary Team Meeting (MDTM) within one day. Methods: We have applied the DMAIC-cycle (Define, Measure, Analyse, Improve and Control) to our processes. The DMAIC-cycle is the management cycle of Lean Six Sigma. Results were measured before implementation of LSS and after for at least one month. Results: After implementing LSS causes for lags in AT, as well as for sending the documented decisions were identified. The lags in AT included patient delay, incomplete referral, official holidays and absences due to medical conferences. After the obstacles were successfully addressed we increased the percentage of patients with an AT ≤ 5 days from 48% to 70%, a 45% improvement. Causes for lags in sending the decisions, included verifying and signing the missive. Currently 99% of referring physicians receive the decision formulated by the MDT in ≤ 1 day. This is a substantial improvement from 2% to 99%. Conclusions: Lean Six Sigma is applicable in a multidisciplinary high care medical facility. Obstacles in the logistics of a complex medical facility can be identified and greatly improved.
Abstract only
730
Background: Multidisciplinary team meetings (MDM) provide a platform for discussing diagnoses and treatments. Since many healthcare settings have accepted multidisciplinary care as ...best practice, avenues towards improving MDMs should be investigated. This study aimed to identify variables that influence the efficiency and efficacy of an MDM in a tertiary referral center in the Netherlands. Methods: Consecutive MDMs for hepatocellular carcinoma (HCC), colorectal carcinoma (CRC), esophageal and gastric cancer (ESOGAS) and pancreatobiliary and liver cancer (HPB) were studied. Efficiency was measured as duration of the MDM. Efficacy was assessed by accurate diagnoses. Logistic and linear regression models identified variables influencing the efficiency and efficacy. Results: In 74 MDMs with a mean duration of 63 min (SD 14), 700 patients were discussed of which 114 patients at ≥2 MDMs. A median of 10 patients was discussed per MDM (IQR 6 – 14). Mean discussion time per patient was 05:19 min (SD 2). Corrected for tumor type, the number of patients discussed and the presence of others (e.g., research fellows) in addition to medical specialists, prolonged the MDM (+1.9 min CI 1.2 – 2.6; +0.64 min; CI 0.23 – 1.5 resp.). Including a follow up patient in the MDM, decreased the duration by 3.9 min (CI -5.8 – -2.0). The diagnostic accuracy of the MDM was 95%. The duration of the MDM or number of patients discussed did not influence this (OR 1.1 CI 0.99 – 1.0; OR 0.92 CI 0.79 – 1.1 resp.). The diagnosis was accurately altered for 117 (21%) patients, for 1 patient it was altered incorrectly. Tumor type predicted the accurate diagnoses (OR 0.1 CI 0.02 – 0.71; OR 2.0 CI 0.46 – 8.6; OR 3.1 CI 1.3 – 7.4; for HCC, CRC and ESOGAS respectively. Reference group: HPB). A correct diagnosis was more likely if patients’ cases were presented by their own doctor (OR 5.0 CI 2.0 – 12.5). Conclusions: MDMs play a crucial role in oncology management. For 21% of patients the diagnosis was correctly altered by the MDM. The diagnostic accuracy of the MDM was 95%. The absence of a presenting doctor decreased this accuracy while duration of MDM and number of patients discussed did not affect this accuracy. The presence of research fellows prolonged the duration of the MDM.
The role of adjuvant chemoradiation in pancreatic cancer remains unclear. This report presents the long-term follow-up results of EORTC trial 40891, which assessed the role of chemoradiation in ...resectable pancreatic cancer.
Two hundred eighteen patients were randomized after resection of the primary tumor. Eligible patients had T1-2 N0-N1a M0 pancreatic cancer or T1-3 N0-N1a M0 periampullary cancers, all histologic proven. Patients in the treatment group (n = 110) underwent postoperative chemoradiation (40 Gy plus 5-FU). Patients in the control group (n = 108) had no further adjuvant treatment.
After a median follow-up of 11.7 years, 173 deaths (79%) have been reported. The overall survival did not differ between the 2 treatment groups (Chemoradiation treatment vs.
death rate ratio 0.91, 95% CI: 0.68-1.23, P value 0.54). The 10-year overall survival was 18% in the whole population of patients (8% in the pancreatic head cancer group and 29% in the periampullary cancer group).
These results confirm the previous short-term analysis, indicating no benefit of adjuvant chemoradiation over observation in patients with resected pancreatic cancer or periampullary cancer. Patients with pancreatic cancer may survive more than 10 years. Only 1 of 31 cases recurred after year 7.
The survival benefit of adjuvant radiotherapy and 5-fluorouracil versus observation alone after surgery was investigated in patients with pancreatic head and periampullary cancers.
A previous study ...of adjuvant radiotherapy and chemotherapy in these cancers by the Gastrointestinal Tract Cancer Cooperative Group of EORTC has been followed by other studies with conflicting results.
Eligible patients with T1-2N0-1aM0 pancreatic head or T1-3N0-1aM0 periampullary cancer and histologically proven adenocarcinoma were randomized after resection.
Between 1987 and 1995, 218 patients were randomized (108 patients in the observation group, 110 patients in the treatment group). Eleven patients were ineligible (five in the observation group and six in the treatment group). Baseline characteristics were comparable between the two groups. One hundred fourteen patients (55%) had pancreatic cancer (54 in the observation group and 60 in the treatment group). In the treatment arm, 21 patients (20%) received no treatment because of postoperative complications or patient refusal. In the treatment group, only minor toxicity was observed. The median duration of survival was 19.0 months for the observation group and 24.5 months in the treatment group (log-rank, p = 0.208). The 2-year survival estimates were 41% and 51 %, respectively. The results when stratifying for tumor location showed a 2-year survival rate of 26% in the observation group and 34% in the treatment group (log-rank, p = 0.099) in pancreatic head cancer; in periampullary cancer, the 2-year survival rate was 63% in the observation group and 67% in the treatment group (log-rank, p = 0.737). No reduction of locoregional recurrence rates was apparent in the groups.
Adjuvant radiotherapy in combination with 5-fluorouracil is safe and well tolerated. However, the benefit in this study was small; routine use of adjuvant chemoradiotherapy is not warranted as standard treatment in cancer of the head of the pancreas or periampullary region.
Surgery for morbid obesity has increased since the introduction of the adjustable gastric bands (AGB), which can be placed laparoscopically. There are two AGB in wide use: the Swedish Adjustable ...Gastric Band (SAGB, Obtech), and the Lap-Band (Inamed Health). We present the results of a comparative study between the 2 AGB.
101 patients with a minimal follow-up of 6 months were included. 49 patients received a Swedish Adjustable Gastric Band (SAGB), and the remaining 52 received the Lap-Band (LB). Postoperative weight loss and complications were compared at set intervals of 3 months in the first postoperative year, and 6 months in the years following.
Mean follow-up was 9.9 months for the SAGB and 7.2 months for the LB. All but 5 procedures were performed laparoscopically. Mean operating-time was 102 minutes for the SAGB and 86 minutes for the LB. No significant difference in complications was noted between the 2 AGB. 1 SAGB was repositioned and 2 were removed, compared to 2 repositions and 2 removals of the LB. We excluded 5 patients with leakage of a SAGB due to technical failure. Mean preoperative weight kg/BMI of the SAGB patients was 133/45.3; in the LB patients 138/46.4. Mean weight loss at 6 months was 28 kg with the SAGB and 30 kg with the LB, and mean weight loss at 1 year 36 kg and 38 kg respectively. After 2 years, weight loss was 46 kg and 42 kg respectively.
There was no significant difference in postoperative weight loss and complications between the SAGB and the LB.
To evaluate the relation between delay in surgery because of preoperative biliary drainage (PBD) and survival in patients scheduled for surgery for pancreatic head cancer.
Patients with obstructive ...jaundice due to pancreatic head cancer can undergo PBD. The associated delay of surgery can lead to more advanced cancer stages at surgical exploration, affecting resection rate and survival.
We conducted a multicenter, randomized controlled clinical trial to compare PBD with early surgery (ES) for pancreatic head cancer for complications. We obtained Kaplan-Meier estimates of overall survival for patients with pathology-proven malignancy and compared survival functions of ES and PBD groups using log-rank test statistics. Multivariable Cox regression analyses were performed to evaluate the prognostic role of time to surgery for overall survival.
Mean times from randomization to surgery were 1.2 (0.9-1.5) and 5.1 (4.8-5.5) weeks in the ES and PBD groups, respectively (P < 0.001). In the ES group, 60 (67%) of 89 patients underwent resection, versus 53 (58%) of 91 patients in the PBD group (P = 0.20). Median survival after randomization was 12.2 (9.1-15.4) months in the ES group versus 12.7 (8.9-16.6) months in the PBD group (P = 0.91). A longer time to surgery was significantly associated with slightly lower mortality rate after surgery (hazard ratio = 0.90, 95% CI, 0.83-0.97), when taking into account resection, bilirubin, complications, pancreatic adenocarcinoma, tumor-positive lymph nodes, and microscopically residual disease.
In patients with pancreatic head cancer, the delay in surgery associated with PBD does not impair or benefit survival rate.
Surgery in patients with obstructive jaundice caused by a periampullary (pancreas, papilla, distal bile duct) tumor is associated with a higher risk of postoperative complications than in ...non-jaundiced patients. Preoperative biliary drainage was introduced in an attempt to improve the general condition and thus reduce postoperative morbidity and mortality. Early studies showed a reduction in morbidity. However, more recently the focus has shifted towards the negative effects of drainage, such as an increase of infectious complications. Whether biliary drainage should always be performed in jaundiced patients remains controversial. The randomized controlled multicenter DROP-trial (DRainage vs. Operation) was conceived to compare the outcome of a 'preoperative biliary drainage strategy' (standard strategy) with that of an 'early-surgery' strategy, with respect to the incidence of severe complications (primary-outcome measure), hospital stay, number of invasive diagnostic tests, costs, and quality of life.
Patients with obstructive jaundice due to a periampullary tumor, eligible for exploration after staging with CT scan, and scheduled to undergo a "curative" resection, will be randomized to either "early surgical treatment" (within one week) or "preoperative biliary drainage" (for 4 weeks) and subsequent surgical treatment (standard treatment). Primary outcome measure is the percentage of severe complications up to 90 days after surgery. The sample size calculation is based on the equivalence design for the primary outcome measure. If equivalence is found, the comparison of the secondary outcomes will be essential in selecting the preferred strategy. Based on a 40% complication rate for early surgical treatment and 48% for preoperative drainage, equivalence is taken to be demonstrated if the percentage of severe complications with early surgical treatment is not more than 10% higher compared to standard treatment: preoperative biliary drainage. Accounting for a 10% dropout, 105 patients are needed in each arm resulting in a study population of 210 (alpha = 0.95, beta = 0.8).
The DROP-trial is a randomized controlled multicenter trial that will provide evidence whether or not preoperative biliary drainage is to be performed in patients with obstructive jaundice due to a periampullary tumor.
What do the results of the DENSE-trial tell? Klinkenbijl, Jean H G; van Leeuwen, Edwin; Verkooijen, Helena M
Nederlands tijdschrift voor geneeskunde,
04/2020, Letnik:
164
Journal Article
The DENSE trial has demonstrated that offering an MRI scan to women with very dense glandular breast tissue and normal results on screening mammography reduces the number of interval cancers by 50%. ...In the women who agreed to undergo an MRI (59%), this reduction was 80% (from 5 per 1000 to 1 per 1000 participants). DENSE will continue in order to answer the only question that is relevant to patients: does additional MRI lead to less invasive treatment and, above all, to a decrease in mortality? Even in the event where additional MRI screening would lead to a decrease in mortality, we still need to have an open discussion on whether investing in additional MRI screening for women with very dense glandular tissue is the most effective way to improve the health of the Dutch female population. Thanks to the great effort of the DENSE research team, such a discussion can be pursued thoroughly, based on facts.
PDF
