Ambulatory Oncology Chair Utilisation in Australia

Ambulatory Oncology Chair Utilisation in Australia

Background

Over the past decades, cancer has increasingly become one of the leading causes of death worldwide (Nagai & Kim, 2017). In 2018, cancer accounted for more than nine million deaths worldwide (Bray et al., 2018). Scientific evidence suggests that cancer is a group of severe health conditions that affect the quality of life across all human societies (Ko et al., 2014). It begins with genetic changes that lead to abnormal and uncontrollable growth of cells, which lead to the formation of a tumour. Usually, these tumours are either malignant or benign and can start in ant tissue or organ of the body. As the current burden of cancer continues to grow exponentially around the globe, research shows that lifestyle factors such as tobacco smoking and change in diet patterns, among other environmental factors are responsible for the development of cancer (Patel et al., 2018). Currently, health care systems have been strained this phenomenon, while communities have been experiencing emotional, physical, and financial strain.

Cancer has been proven to be a significant factor in both the burden and injury of the disease in Australia, having high rate incidence (Crane & Currow, 2016). For instance, in the year 2013, a total of 124465 new cases of the disease were discovered with men taking a higher number at 68936, slightly beating their female counterparts at 55529. Following closely in the year 2017, an approximate figure of 134174 citizens in Australia were expected to be diagnosed, men still leading at 72169 and women standing at 62005 (Luo & O’Connell, 2016). It was also discovered in the same year that the possibility of developing the disease below the age of 85 years was in 1 in 2 for both males and females (Youlden& Aitken, 2015). It was consequently estimated that the number of Australian citizens who could be expected to be diagnosed with cancer in the year 2020 stood at 149990 both men and women. Still, the information never revealed the exact number of men and that of women (Daniels & Pearson, 2017). It was further revealed that the cancer disease was more common in older people as compared to the middle age, especially below the age of 60. For instance, in the year 2013, men with over 60 years diagnosed with cancer took approximately 75% whereas that of women at the same age bracket reflected at 64% (White & Osborn, 2018). This report thus reveals that cancer cases are more prone to men as compared to their female counterparts (van Leeuwen & Emmett, 2016). Further analysis has indicated that the number of Australians diagnosed with cancer has been increasing over the years, but the mortality rates have decreased drastically, implying that the measures put in place especially in ambulatory care settings have been of impeccable support to the patients (Araghi & Engholm, 2019).

Despite the fact that cancer is one of the leading causes of illness in Australia, cancer survival rates and mortality rates have improved over the recent past. However, people from the lower socioeconomic background—such as Torres Strait Islanders and Aboriginals—have lower survival rates and higher mortality rates compared to the people living in metropolitan areas (Australian Institute of Health and Welfare, 2019). Incidences of cancer are classified as either rare or common cancers. Rates of cancer in more than 12 persons per 100,000 are called common cancers. According to a recent report by Australian Institute of Health and Welfare (2019), the most common types of cancer in Australia are breast cancer, lung cancer, melanoma, colorectal cancer, and prostate cancer. On the other hand, rare types of cancer—cancer diagnosed in between 6 and 12 persons per 100, 000 persons include; mesothelioma, cancer of the eye and nose, and bone cancer. Nevertheless, less common or rare cancers account for half of the mortality cases associated with cancer (Australian Institute of Health and Welfare, 2019).

Major Cancer Treatments Modalities:

• Surgery

Surgery is one of the commonly used and effective methods in the treatment of cancer, especially when removing or repairing tissues. Surgery is suitable for benign cancer since the tumour is contained in a one body part. For surgery to be done there must be underlying reasons such as to; diagnose, remove, reduce the risk of reoccurrence, locate the tumour, relieve the symptoms, repair damaged tissues, support body functions, as well as other cancer treatment methods (Cancer Council Victoria, 2016). As surgery evolves to be one of the common methods of cancer treatment in Australia, different types of surgery have emerged. Diagnostic surgery is one of the main types of surgery. It involves the use of biopsy where a small portion of tissue is extracted from the abnormal area and taken to the laboratory for further examination. If the biopsy contains cancerous cells, the oncologists can interpret the type of cancer and its stage of growth. Curative surgery is also another type of surgery that is used in the treatment of cancer. It is used to cure benign tumours that are located in a single area and have not yet spread. Typically, the surgeon removes the tumour and the surrounding healthy tissues.

Palliative surgery that involves the relieving the side effects caused by tumours is also common in the treatment of cancer.  For example, this type of surgery helps in relieving pain and restoring physical functioning, especially when the tumour causes bowel blockage or when it pressures the vital body organs (Sano et al., 2019). There is reconstructive surgery that involves repairing the removed body parts which were extracted during other surgery treatment. This repairing is done by use of other body tissues or false body parts. Besides, preventive surgery is also an essential type of surgery. It is usually done to minimise the risk of developing tumours. For example, an oncologist can decide to have a mastectomy to women with strong family history and genes of breast cancer (Kaurah et al., 2019).

• Radiation Therapy

Radiation therapy, also known as radiotherapy, is one the commonly used therapy in the treatment of malignant tumours (Baskar et al., 2012) It involves the use of increased doses of radiation that destroy or shrink the malignant tumour cells. This therapy works by directly damaging DNA cells that control the growth and multiplication of cells. Currently, radiotherapy is increasingly becoming one of the most common methods of cancer treatment in Australia. Ambulatory care settings have also seen an increased number of cancer patients who receive this form of treatment. According to a recent cancer report by Australian Institute of Health and Welfare (2017), more than 60, 000 persons received government-subsidised radiotherapy, which represented approximately 6 per cent of all the persons with cancer.

Radiation therapy can be administered in three different methods. External beam radiation is one of the commonly used modes of radiation therapy (Yorke, Gelblum & Ford, 2011). This method involves the use of a machine that directs increased energy rays from outside the body into the tumour cells, thereby killing cancerous cells. External beam radiation is commonly used in ambulatory care settings and can be offered for more weeks. Internal radiation therapy—which also referred to as brachytherapy—involves the insertion of radioactive sources inside the body or around the cancerous cells (Link, 2019). In some cases, radiation can be placed in the body, where it is left to work for some period of time. However, appropriate safety precautionary measures must be observed during the process. Finally, there is systemic radiation, which involves the oral or intravenous administration of radioactive drugs to treat specific types of tumours (Link, 2019). Generally, although Australia has seen an increase in the application of radiation, the use of radiotherapy has side effects that can reduce the patient’s quality of life. Some of the common side effects include sore skin in some patients, tiredness, and loss of hair, diarrhoea, and sex and fertility issues, among others.

• Chemotherapy

Chemotherapy is one of the most commonly used types of cancer treatment in Australia (Cancer Council Victoria, 2016). It involves the use of anti-cancer chemical substances or drugs to destroy cancerous cells. Chemotherapy can include a combination of drugs or a single drug and can be combined with radiation therapy. However, it can also be used before or after chemotherapy. According to a recent report by the Australian Institute of Health and Welfare (2017), between 2014 and 2015, there were about 1,090,513 cancer-affiliated hospitalisations in Australia. Out of these cases, approximately 40 per cent (or 440, 561) of the patient were under chemotherapy. The report further highlights that breast cancer and colorectal cancer accounted for 20 per cent and 15 per cent of the patients who received chemotherapy (Australian Institute of Health and Welfare, 2017).

Currently, there are about seven types of chemotherapies that can be used in the treatment of cancer.  Alkylating agents are the most effective drugs that can be used in the treatment of chemotherapy.  They are commonly used when the cancer cells are not actively and rapidly multiplying. These cell-cycle non-specific drugs are typically used to inhibit replication and miscoding of DNA and transcription of RNA, subsequently preventing protein synthesis (Uboldi, 2017). Plant alkaloids are mostly used when the cancers are multiplying rapidly. These cell-cycle specific drugs are used to inhibit topoisomerase enzymes which take place in the replication of DNA, thereby prompting apoptosis (Kumar-Jain, Kumar-Majumder & Roychoudhury, 2017). Other types of chemotherapy that are also effective in the treatment of cancer include antitumor antibiotics, antimetabolites, topoisomerase inhibitors, and miscellaneous antineoplastic.

It is usually administered in different forms like oral chemotherapy, where a patient only takes tablets or pills (Shaw & Butow, 2015). It can also be administered via the intravenous (iv) chemotherapy which intramuscular therapy, which involves an injection into large muscles like the upper arm (Win & Cotterchio, 2016). The other form could be through intraperitoneal chemotherapy which involves an injection into the abdomen (Reid & van Zandwijk, 2016). Chemotherapy is not 100% efficient as it has shown side effects which include damage to the normal cells in the skin, reproductive organs among others responsible for the division and growth, and in the long-run affecting the appearance and self-esteem of the victims (Zargar & Murphy, 2017).

• Targeted therapies

Over the past ten years, the range of targeted therapies has increased exponentially as more scientists continue to concentrate more effective anti-cancer drugs. Targeted cancer therapy involves the use of drugs and substances that stop the action of molecules that facilitate the growth of cancer cells. Today, there are three main types of targeted therapy—signal transduction inhibitors, hormone therapy, and monoclonal antibodies. Monoclonal antibodies are laboratory-made immune systems proteins that are effective in the treatment of cancer cells (Lu et al., 2020). They are usually designed to target specific types of cancer or to help the immune system in fighting cancerous cells. Typically, they can identify cancer cells; hence, boosting the immune system inaccurate identification and destruction of cancer cells. In other cases, monoclonal antibodies work by bringing the T cells closer to cancer cells, thereby helping the immune system to destroy cancerous cells (Campoli et al., 2010). However, regardless of their usefulness in the treatment of cancer, monoclonal antibodies can lead to needle site reactions and skin reactions.

On the other hand, signal transduction inhibitors work by disrupting cell signals so that they can act against the cancerous cells. In this case, they can block the activity of molecules that facilitate transduction of signals between the cells, thereby inhibiting the rapid multiplication of cancer cells (Sever & Brugge, 2015). Just like the other types of target cancer treatment options, hormone therapy has also become essential in the treatment of cancer in ambulatory care. Hormone therapy acts by preventing the growth of hormone sensitive-tumours by interfering with the action of hormones. Other types of target therapy include angiogenesis inhibitors and apoptosis inducers (Cancer Australia, 2019).

As targeted therapy continues to become one of the commonly used methods of cancer treatment, the survival rates of cancer have improved over recent years. Furthermore, due to the ever-increasing demand for cancer care, cancer treatment delivery has shifted from the inpatient setting to predominantly an ambulatory care setting. In the ambulatory care setting, cancer patients are provided with health services streamlined to offer comfort, flexibility as well as a sense of normalcy during their cancer care journey (Hall & Canfell, 2019). For some patients who live close to the day therapy centre, ambulatory care is relatively more easily accessible to some extent (Gordon & Yaxley, 2017).

Theoretical framework

Health Service Planning Framework

Health service planning is a complex concept that has a close connection with political (Queensland Health, 2015). Currently, the health care system is continuing to become increasingly dynamic with community expectations changing rapidly. As a result, delivery of care services requires a rigorous approach to deliver effective care services that meet the modern-day ever-changing and future needs of the community. Due to this need, the concept of health service planning—which can be traced back in the US in 1946 through the enactment of Hill-Burton Act of 1946—comes into play as the only solution to the increasing demands of the current healthcare systems (Queensland Health, 2015). This framework is majorly concerned with appraising the general needs of the community, particularly in establishing the most effective means that can be used to address the needs through appropriate allocation of the available and expected future resources. Therefore, the primary components of the health service planning framework are an assessment of the care needs, developing goals, planning and organizing resources, prioritising care needs, developing a plan to meet the care needs, and executing and monitoring the implemented plan to ensure it meets the set objectives.

The primary purpose of health service planning is to advance and develop the delivery of services in the care setting, particularly in improving the performance of the care system to meet the health needs of the society (Queensland Health, 2015). Other scholars define health service planning as the concept of expanding strategic directions and healthcare policies to provide meaningful services to the community. In this case, the objectives of the healthcare system need to be defined adequately, while the existing healthcare services delivery strategies need to be aligned with the current healthcare resources. Moreover, since this process is future-oriented, it needs to adopt a lasting perspective that can not only address the problems in the contemporary healthcare issues but also other emerging care trends (Queensland Health, 2015).

Besides the health service planning framework being established under the principles of planning for; safe, focused, patient-centred, sustainable, accessible, quality, and culturally responsive services, there are underlying assumptions that underpin this theoretical framework. One of these assumptions is that the hospital and health services are responsible for planning for the local population. In this case, local development planning is undertaken to ensure resources and services needed by the community are available. In the cases where available services are not available, collaborative arrangements should be availed to meet the care needs of the community (Queensland Health, 2015). The other underpinning assumption is that the department of health should undertake state-wide health service planning and mark the areas that need to be prioritized across the state. The department of health should also analysis the demand and supply of healthcare services and act accordingly.

In the context of the Australian healthcare system, and specifically, in determining the chairs utilisation in an oncology ambulatory therapy centre in Brisbane, the concept of health service planning is highly applicable. First and foremost, healthcare needs in Australia vary depending on the health profile of the community and its age structure. Furthermore, the possibility of seeking care is subjective to a wide range of cultural and social factors, as well as policy determination. In this regard, the concept of health service planning comes down to identifying the care needs of the specific target groups. The theory also comes up with determining the most effective ways of delivering effective oncology care services, as well as analysing the utilisation rate of the available oncology services. Furthermore, health service planning will enable the efficient use of scarce oncology resources available in the ambulatory care setting.

Health Services Planning

Cancer care stands out in complex and multidisciplinary, as it requires a variety of diagnostic, specialist and community-based services to meet cancer patient’s health needs (Evans et al., 2014). The health service planning in Queensland has been done by the Department of Health and has been responsible for controlling and directing such plans. The plans have been outlined to include health improvement for the targeted group, cater for the changing demand of health services, enhance health service delivery in all health care facilities, dealing with emerging trends in health as well as new policy formulations (Thomas & Humphreys, 2016). Such plans include the development of neonatal nursing workforce plan responsible for future workforce requirements, promotion of coordination of retrieval services for expectant mothers (Francis & Wong, 2017). To narrow down to the specific interest of this script, Australia has formulated a cancer care state-wide health service strategy of 2014 which is responsible for the provision of public sector cancer care services with a vision for ten years (Janamian & Wells, 2016). The plan includes promotion of the consistency of care across Australia, provision of services through the integrated network and service partners, improvement of consistency in the timely diagnosis of cancer as well support services via information systems, research, and education (Moore & Bray, 2015). As much as Australia strives to ensure quality services in ambulatory care, there have been challenges especially with the staffing models which have failed to match the demand for outpatient treatment (Perera & Sinclair, 2015). This puts the clinics at danger for potential risks such as nursing burn out and poor-quality services to the patients.

The Organization for Economic Co-operation and Development (OECD) has recognized the health care nature of Australia as one of the best in the world. Nevertheless, the system has faced intense pressure due to the increased demand as well as health care costs, complexity in health conditions, among others (McDonald, 2015). The Australian health care program is majorly dealing with the challenge of resource allocation as well as the performance and patient outcomes developments.

Australia has been considered to spend a low amount of money on healthcare from its Gross Domestic Product. It is believed that it has the highest number of qualified physicians and that Australia is the best in terms of hospital spending, utilisation as well as capacity (Ward & Meyer, 2015). Cancer is considered to be common in the old age between 60-80 years old.

Objectives:

The objective of this pilot study is to determine the chairs utilisation in an oncology ambulatory therapy centre in Brisbane and to explore the relationships between factors (cancer type, procedure type, day of work, clinical trial and departments) associated with chairs utilisation.

Methods

Design:

A retrospective analysis of an administrative dataset (CHARM®) with information on chair utilisation for ambulatory oncology patients

Setting:

Data collection and Cleaning:

Data cleaning was conducted by a senior clinician … who has extensive experience and knowledge of the workflows in the ambulatory oncology daycare unit. Data cleaning was conducted in Microsoft Excel®… For patients with double appointment entries on the same day, where the two procedures (e.g. chemotherapy administration plus blood product transfusion) took place concurrently, the longer appointment was retained. For patients with double appointment entries on the same day, where the two appointments did not overlap with each other, both appointments were retained. Where there were missing data or anomalies (negative values), each entry was verified through cross-checking the ieMR, CHARM, and Electronic Scheduling Management System (ESM). Appointments marked as “did not attend” were deleted from the database.

Data Analysis:

All data outputs were exported to IBM Statistical Package for the Social Sciences® (SPSS) Version 25 for data analysis. Descriptive and appropriate bivariate analyses were used to quantify chair occupancy duration and its relationships with other treatment factors such as cancer diagnosis, and treatment type (i.e. treatment pathways versus ad-hoc, non-treatment procedures)

Ethics consideration:

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