Evaluating the quality of medical care.

Pancreatic cancer is the fourth leading cause of cancer-related death among men and women in the United States. A major challenge in treatment remains patients' advanced disease at diagnosis. The NCCN Guidelines for Pancreatic Adenocarcinoma provides recommendations for the diagnosis, evaluation, treatment, and follow-up for patients with pancreatic cancer. Although survival rates remain relatively unchanged, newer modalities of treatment, including targeted therapies, provide hope for improving patient outcomes. Sections of the manuscript have been updated to be concordant with the most recent update to the guidelines. This manuscript focuses on the available systemic therapy approaches, specifically the treatment options for locally advanced and metastatic disease.

Pancreatic adenocarcinoma, Version 2.2021

It is well known that there are significant racial disparities in health care outcomes, including surgery. However, the mechanisms that lead to these disparities are still not fully understood. In this comprehensive review of the currently published surgical disparity literature in the United States, we assess racial disparities in outcomes after surgical procedures, focusing on patient, provider, and systemic factors. The PubMed, EMBASE, and Cochrane Library electronic databases were searched with the keywords: healthcare disparities AND surgery AND outcome AND US. Only primary research articles published between April 1990 and December 2011 were included in the study. Studies analyzing surgical patients of all ages and assessing the endpoints of mortality, morbidity, or the likelihood of receiving surgical therapy were included. A total of 88 articles met the inclusion criteria. This evidence-based review was compiled in a systematic manner, relying on retrospective, cross-sectional, case-control, and prospective studies in the absence of Class I studies. The review found that patient factors such as insurance status and socioeconomic status (SES) need to be further explored, as studies indicated only a premature understanding of the relationship between racial disparities and SES. Provider factors such as differences in surgery rates and treatment by low volume or low quality surgeons also appear to play a role in minority outcome disparities. Finally, systemic factors such as access to care, hospital volume, and hospital patient population have been shown to contribute to disparities, with research consistently demonstrating that equal access to care mitigates outcome disparities.

https://www.journalacs.org/article/S1072-7515(12)01379-8/pdf

Racial disparities in surgical care and outcomes in the United States: a comprehensive review of patient, provider, and systemic factors.

Background: There is a worldwide shortage of health workers, and this issue requires innovative education solutions. Serious gaming and gamification education have the potential to provide a quality, cost-effective, novel approach that is flexible, portable, and enjoyable and allow interaction with tutors and peers. Objective: The aim of this systematic review was to evaluate the effectiveness of serious gaming/gamification for health professions education compared with traditional learning, other types of digital education, or other serious gaming/gamification interventions in terms of patient outcomes, knowledge, skills, professional attitudes, and satisfaction (primary outcomes) as well as economic outcomes of education and adverse events (secondary outcomes). Methods: A comprehensive search of MEDLINE, EMBASE, Web of Knowledge, Educational Resources Information Centre, Cochrane Central Register of Controlled Trials, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature was conducted from 1990 to August 2017. Randomized controlled trials (RCTs) and cluster RCTs were eligible for inclusion. Two reviewers independently searched, screened, and assessed the study quality and extracted data. A meta-analysis was not deemed appropriate due to the heterogeneity of populations, interventions, comparisons, and outcomes. Therefore, a narrative synthesis is presented. Results: A total of 27 RCTs and 3 cluster RCTs with 3634 participants were included. Two studies evaluated gamification interventions, and the remaining evaluated serious gaming interventions. One study reported a small statistically significant difference between serious gaming and digital education of primary care physicians in the time to control blood pressure in a subgroup of their patients already taking antihypertensive medications. There was evidence of a moderate-to-large magnitude of effect from five studies evaluating individually delivered interventions for objectively measured knowledge compared with traditional learning. There was also evidence of a small-to-large magnitude of effect from 10 studies for improved skills compared with traditional learning. Two and four studies suggested equivalence between interventions and controls for knowledge and skills, respectively. Evidence suggested that serious gaming was at least as effective as other digital education modalities for these outcomes. There was insufficient evidence to conclude whether one type of serious gaming/gamification intervention is more effective than any other. There was limited evidence for the effects of serious gaming/gamification on professional attitudes. Serious gaming/gamification may improve satisfaction, but the evidence was limited. Evidence was of low or very low quality for all outcomes. Quality of evidence was downgraded due to the imprecision, inconsistency, and limitations of the study. Conclusions: Serious gaming/gamification appears to be at least as effective as controls, and in many studies, more effective for improving knowledge, skills, and satisfaction. However, the available evidence is mostly of low quality and calls for further rigorous, theory-driven research.

/pdf/serious-gaming-and-gamification-education-in-health-2cr6ce97vt.pdf

Serious Gaming and Gamification Education in Health Professions: Systematic Review.

Importance Substantial progress has been made in cancer diagnosis and treatment, resulting in a steady improvement in cancer survival. The degree of improvement by age, race, and sex remains unclear. Objective To quantify the degree of survival improvement over time by age, race, and sex in the United States. Design, Setting, and Participants Longitudinal analyses of cancer follow-up data from 1990 to 2010, from 1.02 million patients who had been diagnosed as having cancer of the colon or rectum, breast, prostate, lung, liver, pancreas, or ovary from 1990 to 2009 and who were included in 1 of 9 population-based registries of the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program. Main Outcomes and Measures Hazard ratios (HRs) and 95% CIs for cancer-specific death were estimated for patients diagnosed as having any of these cancers during 1995 to 1999, 2000 to 2004, and 2005 to 2009, compared with those diagnosed in 1990 to 1994. Results Significant improvements in survival were found for cancers of the colon or rectum, breast, prostate, lung, and liver. Improvements were more pronounced for younger patients. For patients aged 50 to 64 years and diagnosed from 2005 to 2009, adjusted HRs (95% CIs) were 0.57 (95% CI, 0.55-0.60), 0.48 (95% CI, 0.45-0.51), 0.61 (95% CI, 0.57-0.69), and 0.32 (95% CI, 0.30-0.36), for cancer of the colon or rectum, breast, liver, and prostate, respectively, compared with the same age groups of patients diagnosed during 1990 to 1994. However, the corresponding HRs (95% CIs) for elderly patients (those 75-85 years old) were only 0.88 (95% CI, 0.84-0.92), 0.88 (95% CI, 0.82-0.95), 0.76 (95% CI, 0.69-0.84), and 0.65 (95% CI, 0.61-0.70), for the same 4 cancer sites, respectively. A similar, although weaker, age-related period effect was observed for lung and pancreatic cancers. The adjusted HRs (95% CIs) for lung cancer were 0.75 (95% CI, 0.73-0.77) and 0.84 (95% CI, 0.81-0.86), respectively, for patients aged 50 to 64 years and 75 to 85 years diagnosed between 2005 and 2009, compared with the same age groups of patients diagnosed between 1990 and 1994 (0.73 [95% CI, 0.69-0.77] and 0.90 [95% CI, 0.85-0.95], respectively. Compared with whites or Asians, African Americans experienced greater improvement in prostate cancer survival. From 1990 to 2009, ovarian cancer survival declined among African Americans but improved among whites. No apparent sex difference in the degree of improvement for any non–sex-specific cancer was noted. Conclusions and Relevance Younger patients experienced greater benefit from recent oncology advances than elderly patients. African Americans experienced poorer survival than whites for all cancers, and the racial difference decreased for prostate cancer but increased for ovarian cancer. Identifying factors associated with varied improvement in cancer survival can inform future improvements in cancer care for all.

https://jamanetwork.com/journals/jamaoncology/articlepdf/2118568/coi140012.pdf

Disparities by Race, Age, and Sex in the Improvement of Survival for Major Cancers: Results From the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program in the United States, 1990 to 2010.

Introduction
There are little data available regarding compliance with the National Comprehensive Cancer Network (NCCN) guidelines. We investigated variation in the management of pancreatic cancer (PC) among large hospitals in California, USA, specifically to evaluate whether compliance with NCCN guidelines correlates with patient outcomes.

Failure to comply with NCCN guidelines for the management of pancreatic cancer compromises outcomes

Objectives To define current use of surgical therapies for hepatocellular carcinoma (HCC) and evaluate the correlation of various patient and hospital characteristics with the receipt of these interventions. Design Retrospective cohort. Setting California Cancer Registry data linked to the Office of Statewide Health Planning and Development patient discharge abstracts between 1996 and 2006. Patients Patients with primary HCC. Main Outcome Measures Receipt of liver transplant, hepatic resection, or local ablation. Results Of 12 148 HCC cases, 2390 (20%) underwent surgical intervention. Three hundred eleven (2.56%) received a liver transplant, 1307 (10.8%) underwent resection, and 772 (6.35%) had local ablation. There were wide variations in treatment by race and hospital type. African American and Hispanic patients were less likely than white patients to undergo transplant (P  Conclusion There are significant racial, socioeconomic, and hospital-type disparities in surgical treatment of HCC.

/pdf/predictors-of-surgical-intervention-for-hepatocellular-4tq5ulmtyg.pdf

Predictors of Surgical Intervention for Hepatocellular Carcinoma: Race, Socioeconomic Status, and Hospital Type

BACKGROUND Limited data are available on the implementation and effectiveness of NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Gastric Cancer. PURPOSE We sought to assess rates of compliance with NCCN Guidelines, specifically stage-specific therapy during the initial episode of care, and to determine its impact on outcomes. METHODS The California Cancer Registry was used to identify cases of gastric cancer from 2001 to 2006. Logistic regression and Cox proportional hazard models were used to predict guideline compliance and the adjusted hazard ratio for mortality. Patients with TNM staging or summary stage (SS) were also analyzed separately. RESULTS Compliance with NCCN Guidelines occurred in just 45.5% of patients overall. Patients older than 55 years were less likely to receive guideline-compliant care, and compliance was associated with a median survival of 20 versus 7 months for noncompliant care (P<.001). Compliant care was also associated with a 55% decreased hazard of mortality (P<.001). Further analysis revealed that 50% of patients had complete TNM staging versus an SS, and TNM-staged patients were more likely to receive compliant care (odds ratio, 1.59; P<.001). TNM-staged patients receiving compliant care had a median survival of 25.3 months compared with 15.1 months for compliant SS patients. CONCLUSIONS Compliance with NCCN Guidelines and stage-specific therapy at presentation for the treatment of patients with gastric cancer was poor, which was a significant finding given that compliant care was associated with a 55% reduction in the hazard of death. Additionally, patients with TNM-staged cancer were more likely to receive compliant care, perhaps a result of having received more intensive therapy. Combined with the improved survival among compliant TNM-staged patients, these differences have meaningful implications for health services research.

Compliance with gastric cancer guidelines is associated with improved outcomes.

Recently, renewed interest in and fear of recurrent colorectal cancer has arisen, which has become the focus of public attention. Based on recent American Cancer Society statistics, colorectal cancer is the fourth most common cancer in the United States (US), as well as the third most common cause of cancer-related death in both men and women. Up to half of newly diagnosed cases will result in deaths within 5 years. In the year 2006 alone, there were 148,610 individuals diagnosed with colorectal cancer in the US, 55,170 of whom died during that year. If we look at yearly statistics between 2001 and 2005, the incidence of this disease was 134,400 in 2001, 148,300 in 2002, 147,500 in 2003, 146,940 in 2004, and 144,986 in 2005. Estimated deaths during that time were 55,170 in 2001, 56,600 in 2002, 56,730 in 2003, 56,660 in 2004, and 56,660 in 2005. This is in contrast to the decline of incidence rates by 1.8% per year between 1985 and 1995, and their stabilization during the period of 1995–1999 (perhaps due to the increased screening for polyps). Thus, the incidence of and mortality rate for colorectal cancer have not decreased appreciably over the last decade. A deeper understanding of the significance of risk factors such as family history of polyps and colorectal cancer, presence of inflammatory bowel disease, alcohol consumption, obesity, physical inactivity, smoking, high fat and/or low fiber diet, coupled with corresponding lifestyle changes and an emphasis on screening (routine fecal occult blood testing plus sigmoidoscopy or colonoscopy), will perhaps reduce the incidence of colorectal cancer in the next decade. Agents with chemopreventive activity such as non-steroidal anti-inflammatory drugs (NSAIDS), estrogen supplementation in women with or without progesterone, and naturally occurring substances such as curcumin, may also reduce the incidence of colorectal cancer, particularly in high-risk groups such as patients affected by a hereditary colorectal cancer syndrome (i.e., hereditary non-polyposis colorectal cancer and familial adenomatous polyposis). Primary treatment of colorectal cancer almost always involves surgery. After this initial intervention, more than 50% of patients will experience recurrence of the disease, and will be subject to a prolonged, agonizing downhill course—physically, emotionally, and psychologically—until the end of their lives. This is, in part, due to the fact that at present, only 37% of colorectal cancers are detected at an early stage. Oneand 5-year overall survival rates across all stages of colorectal cancer are 83% and 62%, respectively. When colorectal cancer is detected early, 5-year survival may be as high as 90%. Once regional lymph nodes are involved, survival decreases to approximately 65%. When distant metastases are present, 5-year survival is a dismal 9%. Recurrence patterns can be either loco-regional (anastomotic, pelvic or tumor bed, and nodal) or distant (hepatic, pulmonary, peritoneal, and osseous). A recent single-institution study compared a treatment group of 710 patients with colon and rectal cancer treated between 1996 and 2006 with a control group of 475 patients treated between 1989 and 1995. A trend toward an increased time until recurrence (2.1 vs. 1.6 years), and a significant decrease in the 5-year rate of both local and distant recurrence (17% vs. 42% for overall recurrence) was observed in favor of the study group when only patients undergoing curative resection were considered [1]. This study also showed a significant reduction of local recurrence in patients with rectal cancer in favor of the study group (9% vs. 34%). Thus, despite the overall statistics given above, results of this large-scale study are indeed encouraging. Although it was previously believed that the majority of colorectal cancer recurrences occur within 2–3 years, a longer period of time may be required to detect all recurrences in a given series. A recent Japanese study examined 246 patients who underwent curative resection of colon cancer and 169 patients who had surgery with curative intent for rectal cancer [2]. At 10 years of follow-up, 6% of patients were lost to follow-up and 34% had died. The most common site of recurrence was the liver for colon cancer and loco-regional pelvic recurrence for rectal cancer. For colon cancer, 100% of recurrences were detected within 4 years of initial surgery, while for rectal cancer 89% were diagnosed at 5 years, 98% at 7 years, and 100% at 10 years of follow-up. This suggests that in patients with curatively resected rectal cancer, a longer duration of close surveillance is necessary, particularly in patients receiving neoadjuvant chemoradiation therapy. At present, the most widely used method of detection for colorectal cancer recurrence in the liver or regionally is the monitoring of carcinoembryonic antigen (CEA). In one Greek study of colorectal cancer patients without clinical evidence of hepatic lesions [3], CEA levels in portal blood and bile drawn at the time of curative resection were good indicators of subsequent hepatic metastases (sensitivities 92% and 100%, respectively). However, poor specificity resulted in an overall accuracy of less than 60%. Therefore, although quantitative CEA measurement is not sufficiently accurate to guide individual management decisions, it may identify a group at high-risk for development of secondary hepatic tumors. These high-risk patients

https://onlinelibrary.wiley.com/doi/pdf/10.1002/jso.20882

Patterns of recurrence of colorectal cancer.

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