CONTINUING MEDICAL EDUCATION PROGRAM
JACS CME-1 FEATURED ARTICLE, VOLUME 203, OCTOBER 2006 Locoregional recurrence after mastectomy: incidence and outcomes Buchanan CL, Dorjn PL, Fey J, et al J Am Coll Surg 2006;203:469–474 Tension-free repair versus watchful waiting for men with asymptomatic or minimally symptomatic inguinal hernias: a cost effectiveness analysis Stroupe KT, Manheim LM, Luo P, et al J Am Coll Surg 2006;203:458–468 You can earn two CME credits using JACS CME Online, at http://jacscme.facs.org, or you can earn two CME credits if you submit this page by fax (see instructions in box below). JACS CME Online provides four articles from each issue for four credits per month. The articles this month on JACS CME Online are: Locoregional recurrence after mastectomy: incidence and outcomes. Buchanan CL, Dorjn PL, Fey J, et al. Tension-free repair versus watchful waiting for men with asymptomatic or minimally symptomatic inguinal hernias: a cost effectiveness analysis. Stroupe KT, Manheim LM, Luo P, et al. Role of rectosignoidectomy and stripping of pelvic peritoneum in outcomes of patients with advanced ovarian cancer. Aletti GD, Podratz KC, Jones MB, Cliby WA. Outcomes after ruptured abdominal aortic aneurysms— the ‘halo effect’ of trauma center designation. Utter GH, Maier RV, Rivara FP, Nathens AB.
Objectives: After reading the featured articles published in this issue of the Journal of the American College of Surgeons (JACS) participants in the JACS CME pro- gram should be able to demonstrate increased under- standing of the material specific to the article featured and be able to apply relevant information to clinical practice. Objectives are stated at the beginning of each featured article; the questions follow with five response choices, and a critique discussing the objective. The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The JACS CME program fulfills the ACCME essentials. The American College of Surgeons designates this educational activity for a maximum of 2 Category 1 credits toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/ she actually spent in the educational activity.
Questions: Wendy Cowles Husser, MA, MPA Executive Editor, JACS 633 N Saint Clair Street, Chicago, IL 60611 312-202-5306 (ph) 312-202-5027 (fax) [email protected]
© 2006 by the American College of Surgeons Published by Elsevier Inc.
ISSN 1072-7515/06/$32.00 doi:10.1016/j.jamcollsurg.2006.07.007
Continuing Medical Education Program
Locoregional recurrence after mastectomy: incidence and outcomes
Buchanan CL, Dorjn PL, Fey J, et al J Am Coll Surg 2006;203:469–474 Learning Objectives: After study of this article, the surgeon will know the incidence and be able to describe the appropriate work-up and treatment of post-mastectomy local recurrences. Question 1
The incidence of local recurrences following mastectomy: a) b) c) d) e)
should be less than 3% with good surgical technique. is not affected by the use of adjuvant therapies. increases with advancing age. is higher in patients with lobular histology. is 9% in the current study.
Critique: Local recurrences are a devastating event following mastectomy and may occur more commonly than previously accepted, probably because patients receiving mastectomy are often at advanced stages. Local recurrences are more common in young patients, those with skin involvement, multicentric tumors, lymphovascular invasion and positive nodes. In the current study of 1057 patients undergoing mastectomy, we found a 9% incidence of local recurrence following mastectomy, despite the widespread use of adjuvant therapies, all of which have previously been shown to lower local recurrence rates. Question 2
Local recurrences after mastectomy: a) b) c) d) e)
are always associated with distant metastatic disease. should always be treated with immediate surgery. are common in Stage 1 and 2 patients. should always prompt a search for metastatic disease. are impossible to eradicate even with multimodality treatment.
Critique: The high rate of local recurrences observed in our study was probably due to the high stage at presentation since stage at diagnosis is clearly a factor in predicting local recurrence. In our Stage 1 patients, only 4% developed local recurrences compared to 14% of stage 3 patients. While local recurrences are isolated events, in some cases, about a third of patients will have synchronous distant disease. Therefore, when initially detected, a search for distant disease is warranted. If no distant disease is found, attempts at rendering the patient free of disease with a combination of surgery, radiation and /or systemic chemo or hormonal
J Am Coll Surg
therapy is warranted because many can be NED. In our study, 41% of the patients not found to have distant disease at the time of presentation of their local recurrence remained free of distant disease at 4 years. Nevertheless, continued vigilance is advised. The treatment of isolated local recurrence should not be considered palliative and aggressive therapy appears warranted in the absence of distant disease. Tension-free repair versus watchful waiting for men with asymptomatic or minimally symptomatic inguinal hernias: a cost effectiveness analysis
Stroupe KT, Manheim LM, Luo P, et al* J Am Coll Surg 2006;203:458–468 Learning Objectives: After study of this article, the surgeon will be able to describe the data needed for estimation of cost-effectiveness, and the overall role of cost-effectiveness in therapeutic decision-making. Question 1
Which data must be collected to be sufficient to estimate the cost-effectiveness of a surgical procedure relative to another procedure or treatment (eg, watchful waiting)? Choose the best and most complete answer. a) Costs directly associated with the operation or treatment, including operating room charges and supplies, hospital charges, and anesthesiologists’ fees. b) Costs of the procedure and patient’s quality of life, measured before and 6 weeks after the operation. c) Hospital and physician charges for the procedure. d) Costs of the procedure or treatment and costs of follow-up care, and patient outcomes, such as quality of life. e) Patient outcomes, such as quality of life as measured by surveys of patient satisfaction.
Critique: The cost-effectiveness of a procedure relative to another procedure or treatment is estimated using a set of measures that are comprehensive and include all the costs incurred by the patient or payer, including costs of hospital and outpatient care and costs of physicians’ services, and patient outcomes (e.g., health-related quality of life as measured by standard questionnaires administered to patients, such as the SF-36). It is important to gather these data if cost-effectiveness is to be examined, a practice that is increasingly used by payers including governmental programs, large insurers, and managed care organizations. Costs are used rather than charges, *Dr Olga Jonasson, JACS Education Editor, is a coauthor of this article.
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because charges may vary for reasons, such as institutional factors, unrelated to underlying health care costs. These data should also be collected during the postoperative period and convalescence, to capture the real costs of the procedure. Patient outcomes in a costeffectiveness analysis may include a variety of measures such as symptoms relieved, improved health-related quality of life, life-years gained, etc. A Panel on CostEffectiveness in Health and Medicine convened by the U.S. Public Health Service has published guidelines for conducting cost-effectiveness analyses and recommends that effectiveness be measured using quality-adjusted life years (QALYs). QALYs capture both health-related quality of life and survival into a single measure, providing a broad measure of effectiveness that facilitates comparison of cost-effectiveness results across a variety of other procedures and treatments. QALYs use communitywide preferences for the health states that occurred during each time period (e.g., year) to “quality adjust” each time period. The preferences are given values between 0 (representing death) and 1 (representing perfect health). For example, if a patient survived for 2 years following a procedure and had 1.5 QALYs, then 1.5 years in perfect health would be preferred as much as 2 years in the patient’s actual health state. When combined with the cost data, it is determined how much an additional period of “good” quality of life would cost. These calculations are beyond the capability of individual surgeons, but the data needed to make the calculations can only come with the participation of surgeons and hospitals. Question 2
How is an assessment of the cost-effectiveness of a surgical procedure relative to another procedure or treatment used?
Continuing Medical Education Program
a) To ration health care. b) To determine if the procedure is worthwhile. c) To establish charges in a uniform manner across healthcare systems. d) To determine whether a procedure will be cost-saving relative to another procedure for an individual patient. e) To restrict surgical privileges for individual surgeons whose outcomes are most costly.
Critique: While many complex and/or costly surgical procedures are possible to perform successfully, the surgeon is faced with the question: “I can do this procedure, but should I do it?” The answer to this question relates to the “appropriateness” of our decisions about a procedure. Cost-effectiveness is not used to ration health care, but rather to assist in determining if a procedure is worthwhile relative to other procedures or treatments (including watchful waiting). It cannot establish costs, which are relatively fixed in an institution (sutures, instruments, drugs, etc.). It can provide information about the average costs resulting from a procedure, but it cannot be used to determine whether a procedure will be cost-saving for an individual patient. Moreover, even if a procedure is not cost-saving it may still be worthwhile if decision makers are willing to pay the additional costs for the improvement in outcomes. It cannot be used to assess the performance of an individual physician because the calculations are based on total hospital and follow-up costs, not on those of an individual surgeon. It is useful to conduct cost-effectiveness as part of a randomized clinical trial, such as was the case in this article, because the needed data including health-related quality of life and both inpatient and outpatient costs can be collected during the course of the trial.