Patient empowerment reflects the ability of patients to positively influence their health and health behavior such as physical activity. While interactive Web-based interventions are increasingly ...used in various chronic disease settings to enhance empowerment and physical activity, such interventions are still uncommon for cancer survivors.
The objective of this study was to systematically review the literature regarding interactive Web-based interventions. We focused on interventions aimed at increasing patient empowerment and physical activity for various chronic conditions, and explored their possible relevance for cancer survivors.
Searches were performed in PubMed, Embase, and Scopus to identify peer-reviewed papers reporting on randomized controlled trials that studied the effects of Web-based interventions. These interventions were developed for adults with diabetes, cardiovascular disease, chronic obstructive pulmonary disease, heart failure, or cancer. Intervention characteristics, effects on patient empowerment and physical activity, information on barriers to and facilitators of intervention use, users' experiences, and methodological quality were assessed. Results were summarized in a qualitative way. We used the recommendations of the Institute of Medicine (IOM) regarding cancer survivorship care to explore the relevance of the interventions for cancer survivors.
We included 19 papers reporting on trials with 18 unique studies. Significant, positive effects on patient empowerment were reported by 4 studies and 2 studies reported positive effects on physical activity. The remaining studies yielded mixed results or no significant group differences in these outcomes (ie, no change or improvement for all groups). Although the content, duration, and frequency of interventions varied considerably across studies, commonly used elements included education, self-monitoring, feedback/tailored information, self-management training, personal exercise program, and communication (eg, chat, email) with either health care providers or patients. Limited information was found on barriers, facilitators, and users' experiences. Methodological quality varied, with 13 studies being of moderate quality. The reported Web-based intervention elements appeared to be highly relevant to address the specific needs of cancer survivors as indicated by the IOM.
We identified 7 common elements of interactive, Web-based interventions in chronic disease settings that could possibly be translated into eHealth recommendations for cancer survivors. While further work is needed to determine optimal intervention characteristics, the work performed in other chronic disease settings provides a basis for the design of an interactive eHealth approach to improve patient empowerment and physical activity in cancer survivors. This may subsequently improve their health status and quality of life and reduce their need for supportive care.
We evaluated the effectiveness of a low-intensity, home-based physical activity program (Onco-Move) and a moderate- to high-intensity, combined supervised resistance and aerobic exercise program ...(OnTrack) versus usual care (UC) in maintaining or enhancing physical fitness, minimizing fatigue, enhancing health-related quality of life, and optimizing chemotherapy completion rates in patients undergoing adjuvant chemotherapy for breast cancer.
We randomly assigned patients who were scheduled to undergo adjuvant chemotherapy (N = 230) to Onco-Move, OnTrack, or UC. Performance-based and self-reported outcomes were assessed before random assignment, at the end of chemotherapy, and at the 6-month follow-up. We used generalized estimating equations to compare the groups over time.
Onco-Move and OnTrack resulted in less decline in cardiorespiratory fitness (P < .001), better physical functioning (P ≤ .001), less nausea and vomiting (P = .029 and .031, respectively) and less pain (P = .003 and .011, respectively) compared with UC. OnTrack also resulted in better outcomes for muscle strength (P = .002) and physical fatigue (P < .001). At the 6-month follow-up, most outcomes returned to baseline levels for all three groups. A smaller percentage of participants in OnTrack required chemotherapy dose adjustments than those in the UC or Onco-Move groups (P = .002). Both intervention groups returned earlier (P = .012), as well as for more hours per week (P = .014), to work than the control group.
A supervised, moderate- to high-intensity, combined resistance and aerobic exercise program is most effective for patients with breast cancer undergoing adjuvant chemotherapy. A home-based, low-intensity physical activity program represents a viable alternative for women who are unable or unwilling to follow the higher intensity program.
•The costs of R&D are crucial in the debate on high drug prices.•An emergent technology that could transform R&D efficiency is organ-on-a-chip.•Experts estimate the potential of organ-on-a-chip to ...reduce R&D costs by 10–26%.•Improvements in success rates are expected to drive savings.•Most impacted are the lead optimization and preclinical phases of R&D.
Healthcare systems are faced with the challenge of providing innovative treatments, while shouldering high drug costs that pharmaceutical companies justify by the high costs of R&D. An emergent technology that could transform R&D efficiency is organ-on-a-chip. The technology bridges the gap between preclinical testing and human trials through better predictive models, significantly impacting R&D costs. Here, we present an expert survey on the future role of organ-on-a-chip in drug discovery and its potential quantitative impact. We find that the technology has the potential to reduce R&D costs significantly, driven by changes in direct costs, success rates and the length of the R&D process. Finally, we discuss regulatory challenges to efficiency improvements.
External-beam radiotherapy treatments are delivered by a linear accelerator (linac) in a series of high-energy radiation sessions over multiple days. With the increase in the incidence of cancer and ...the use of radiotherapy (RT), the problem of automatically scheduling RT sessions while satisfying patient preferences regarding the time of their appointments becomes increasingly relevant. While most literature focuses on timeliness of treatments, several Dutch RT centers have expressed their need to include patient preferences when scheduling appointments for irradiation sessions. In this study, we propose a mixed-integer linear programming (MILP) model that solves the problem of scheduling and sequencing RT sessions considering time window preferences given by patients. The MILP model alone is able to solve the problem to optimality, scheduling all sessions within the desired window, in reasonable time for small size instances up to 66 patients and 2 linacs per week. For larger centers, we propose a heuristic method that pre-assigns patients to linacs to decompose the problem in subproblems (clusters of linacs) before using the MILP model to solve the subproblems to optimality in a sequential manner. We test our methodology using real-world data from a large Dutch RT center (8 linacs). Results show that, combining the heuristic with the MILP model, the problem can be solved in reasonable computation time with as few as 2.8% of the sessions being scheduled outside the desired time window.
•Distance-based interventions may increase physical activity levels of cancer survivors.•Overall, reviewed distance-based interventions showed a very small and limited effect on physical activity ...behavior.•Studies are targeting a subset of cancer survivors which limits generalizability.•Many studies have methodological limitations that limits inferences that can be drawn.•New approaches are needed to facilitate and support physical activity levels of cancer survivors.
Physically active cancer survivors have a reduced risk of cancer recurrence and mortality. Given the health advantages of active lifestyles in cancer survivorship, as well as the barriers preventing physical activity (e.g., geography, time) there is a need to develop and evaluate effective physical activity interventions that employ distance-based (i.e., non face-to-face) approaches. The primary objective of this study was to provide a systematic review and meta-analysis of present-day (2013–2018) distance-based physical activity behaviour change interventions for cancer survivors.
PubMed and Embase databases were searched from November 2012 up to June 2018. Studies were included that met the following criteria: (1) written in English, (2) included adult cancer survivors (either undergoing or completed treatment), (3) was a controlled intervention study, and (4) the intervention was distance-based (delivered via distance) with no more than one face-to-face contact. Review Manager 5 (RevMan 5) software was used to perform a meta-analysis on all randomized controlled trials (RCTs) that presented self-reported or objectively measured physical activity post-intervention means and standard deviations. Risk of bias for each study was assessed using The Cochrane Risk of Bias Tool.
We included 29 RCTs. Across the 29 studies, the total number of participants in these studies was 5218. Median sample size was 95 and ranged from 19 to 463. Thirteen (45%) studies focused on breast cancer survivors and median months since diagnosis was 24 (range 6–79). Moderate-to-vigorous intensity physical activity data from 24 RCTs were included in the meta-analysis and indicated an overall small effect (standardized mean difference) of 0.21 (95% CI 0.11–0.32) favoring the interventions.
Intervention effects on physical activity were small. Drawing conclusions from these trials remains challenging given major limitations of these trials included poor methodological design, small sample sizes, lack of statistical power, homogeneous samples (e.g., caucasian, young, well-educated), and poor measures of physical activity (e.g., self-report). Relying on the present landscape of distance-based programs aiming to facilitate physical activity among cancer survivors may not be prudent.
To improve quality of care, centralisation of cancer services in high-volume centres has been stimulated. Studies linking specialisation and high (surgical) volumes to better outcomes already ...appeared in the 1990's. However, actual centralisation was a difficult process in many countries. In this study, factors influencing the centralisation of cancer services in the Netherlands were determined.
Centralisation patterns were studied for three types of cancer that are known to benefit from high surgical caseloads: oesophagus-, pancreas- and bladder cancer. The Netherlands Cancer Registry provided data on tumour and treatment characteristics from 2000-2013 for respectively 8037, 4747 and 6362 patients receiving surgery. By plotting timelines of centralisation of cancer surgery, relations with the appearance of (inter)national scientific evidence, actions of medical specialist societies, specific regulation and other important factors on the degree of centralisation were ascertained.
For oesophagus and pancreas cancer, a gradual increase in centralisation of surgery is seen from 2005 and 2006 onwards following (inter)national scientific evidence. Centralisation steps for bladder cancer surgery can be seen in 2010 and 2013 anticipating on the publication of norms by the professional society. The most influential stimulus seems to have been regulations on minimum volumes.
Scientific evidence on the relationship between volume and outcome lead to the start of centralisation of surgical cancer care in the Netherlands. Once a body of evidence has been established on organisational change that influences professional practice, in addition some form of regulation is needed to ensure widespread implementation.
The number of patient portals is rising, and although portals can have positive effects, their implementation has major impacts on the providing health care institutions. However, little is known ...about the organizational factors affecting successful implementation. Knowledge of the specific barriers to and facilitators of various stakeholders is likely to be useful for future implementations.
The objective of this study was to identify the barriers to and facilitators of patient portal implementation facing various stakeholders within hospital organizations in the Netherlands.
Purposive sampling was used to select hospitals of various types. A total of 2 university medical centers, 3 teaching hospitals, and 2 general hospitals were included. For each, 3 stakeholders were interviewed: (1) medical professionals, (2) managers, and (3) information technology employees. In total, 21 semistructured interviews were conducted using the Grol and Wensing model, which describes barriers to and facilitators of change in health care practice at 6 levels: (1) innovation; (2) individual professional; (3) patient; (4) social context; (5) organizational context; and (6) economic and political context. Two researchers independently selected and coded quotes by applying this model using a (deductive) directed content approach. Additional factors related to technical and portal characteristics were added using the model of McGinn et al, developed for implementation of electronic health records.
In total, we identified 376 quotes, 26 barriers, and 28 facilitators. Thirteen barriers and 12 facilitators were common for all stakeholder groups. The facilitators' perceived usefulness (especially less paperwork) was mentioned by all the stakeholders, followed by subjects' positive attitude. The main barriers were lack of resources (namely, lack of staff and materials), financial difficulties (especially complying with high costs, lack of reimbursements), and guaranteeing privacy and security (eg, strict regulations). Both similarities and differences were found between stakeholder groups and hospital types. For example, managers and information technology employees mainly considered guaranteeing privacy and security as a predominant barrier. Financial difficulties were particularly mentioned by medical professionals and managers.
Patient portal implementation is a complex process and is not only a technical process but also affects the organization and its staff. Barriers and facilitators occurred at various levels and differed among hospital types (eg, lack of accessibility) and stakeholder groups (eg, sufficient resources) in terms of several factors. Our findings underscore the importance of involving multiple stakeholders in portal implementations. We identified a set of barriers and facilitators that are likely to be useful in making strategic and efficient implementation plans.
Robot-Assisted Radical Prostatectomy (RARP) is one of the standard treatment options for prostate cancer. However, controversy still exists on its added value. Based on a recent large-sample ...retrospective cluster study from the Netherlands showing significantly improved long-term urinary functioning after RARP compared to Laparoscopic RP (LRP), we evaluated the cost-effectiveness of RARP compared to LRP. A decision tree was constructed to measure the costs and effects from a Dutch societal perspective over a ~ 7 year time-horizon. The input was based on the aforementioned study, including patient-reported consumption of addition care and consumed care for ergonomic issues reported by surgeons. Intervention costs were calculated using a bottom-up costing analysis in 5 hospitals. Finally, a probabilistic-, one-way sensitivity- and scenario analyses were performed to show possible decision uncertainty. The intervention costs were €9964 for RARP and €7253 for LRP. Total trajectory costs were €12,078 for RARP and €10,049 for LRP. RARP showed higher QALYs compared to LRP (6.17 vs 6.11). The incremental cost-utility ratio (ICUR) was €34,206 per QALY gained, in favour of RARP. As a best-case scenario, when RARP is being centralized (> 150 cases/year), total trajectory costs decreased to €10,377 having a higher utilization, and a shorter procedure time and length of stay resulting in an ICUR of €3495 per QALY gained. RARP showed to be cost-effective compared to LRP based on data from a population-based, large scale study with 7 years of follow-up. This is a clear incentive to fully reimburse RARP, especially when hospitals provide RARP centralized.
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