Biomedical subjects

Carmen D Dirksen

Publications and source records attributed to Carmen D Dirksen.

8 recordsLinked to original sources

PubMed2007

Improving the quality and efficiency of follow-up after curative treatment for breast cancer--rationale and study design of the MaCare trial.

BACKGROUND: After curative treatment for breast cancer women frequently attend scheduled follow-up examinations. Usually the follow-up is most frequent in the first 2-3 years (2-4 times a year); thereafter the frequency is reduced to once a year in most countries. Its main aim is to detect local disease recurrence, or a second primary breast cancer, but also to provide information and psychosocial support. However, the cost-effectiveness of these frequent visits is under much debate, leading to a search for less intensive and more cost-effective follow-up strategies. In this paper the design of the MaCare trial is described. This trial compares the cost-effectiveness of four follow-up strategies for curatively treated breast cancer patients. We investigate the costs and effects of nurse-led telephone follow-up and a short educational group programme. METHODS/DESIGN: The MaCare trial is a multi centre randomised clinical trial in which 320 breast cancer patients are randomised into four follow-up strategies, focussed on the first 18 months after treatment: 1) standard follow-up; 2) nurse-led telephone follow-up; 3) arm 1 with the educational group programme; 4) arm 2 with the educational group programme. Data is collected at baseline and 3, 6, 12 and 18 months after treatment. The primary endpoint of the trial is cancer-specific quality of life as measured by the global health/QoL scale of the EORTC QLQ-C30. Secondary outcomes are perceived feelings of control, anxiety, patients' satisfaction with follow-up and costs. A cost-effectiveness analysis will be performed from a societal perspective. DISCUSSION: Reduced follow-up strategies for breast cancer have not yet been widely applied in clinical practice. Improvement of psychosocial support and information to patients could lead to a better acceptance of reduced follow-up. The MaCare trial combines a reduced follow-up strategy with additional psychosocial support. Less frequent follow-up can reduce the burden on medical specialists and costs. The educational group programme can improve QoL of patients, but also less frequent follow-up can improve QoL by reducing the anxiety experienced for each follow-up visit. Results of the trial will provide knowledge on both costs and psychosocial aspects regarding follow-up and are expected in 2009.

Breast Neoplasms↗

PubMed2007

GP concordance with advice for treatment following a multidisciplinary psychogeriatric assessment.

OBJECTIVE: To evaluate the concordance of General Practitioners (GPs) with advice for treatment after a multidisciplinary psychogeriatric assessment by the Diagnostic Observation Centre for PsychoGeriatric patients (DOC-PG). METHOD: Concordance checklists, listing the recommendations from the multidisciplinary team, were sent to the GPs in order to establish GP concordance. Regression models were used to study the associations between various patient and GP characteristics and level of concordance. Furthermore, results of a questionnaire (to identify the level of satisfaction regarding the services provided by the DOC-PG) were compared with the level of GP concordance. RESULTS: Based on 530 recommendations, the overall GP concordance rate amounted to 71%. The most common types of advice pertained to medication, GP follow-up/advice and referral. GP concordance with advice regarding admissions was the highest, followed by advice concerning the arrangement of daycare, home care and the adaptation of medication. GP concordance was lowest for referral recommendations to other specialties and recommendations regarding psychoeducation. Concordance was higher for patients who lived alone, for patients with fewer cognitive problems, when the number of recommendations did not exceed six and in group practices. Concordance was dependent on the type of advice. Satisfaction with DOC-PG did not correlate with the level of concordance. CONCLUSIONS: In general, GPs showed a high level of concordance with advice from the DOC-PG. Enhancement of GP concordance can be achieved by limiting the number of recommendations, giving detailed explanations about the purpose of recommendations and educating GPs by doing.

Aged↗

PubMed2006

Single versus double embryo transfer: cost-effectiveness analysis alongside a randomized clinical trial.

BACKGROUND: Twin pregnancies after IVF are still frequent and are considered high-risk pregnancies leading to high costs. Transferring one embryo can reduce the twin pregnancy rate. We compared cost-effectiveness of one fresh cycle elective single embryo transfer (eSET) versus one fresh cycle double embryo transfer (DET) in an unselected patient population. METHODS: Patients starting their first IVF cycle were randomized between eSET and DET. Societal costs per couple were determined empirically, from hormonal stimulation up to 42 weeks after embryo transfer. An incremental cost-effectiveness ratio (ICER) was calculated, representing additional costs per successful pregnancy. RESULTS: Successful pregnancy rates were 20.8% for eSET and 39.6% for DET. Societal costs per couple were significantly lower after eSET (7334 euro) compared with DET (10,924 euro). The ICER of DET compared with eSET was 19,096 euro, meaning that each additional successful pregnancy in the DET group will cost 19,096 euro extra. CONCLUSIONS: One cycle eSET was less expensive, but also less effective compared to one cycle DET. It depends on the society's willingness to pay for one extra successful pregnancy, whether one cycle DET is preferred from a cost-effectiveness point of view.

Adult↗

PubMed2006

Cost-effectiveness of Mohs Micrographic Surgery vs Surgical Excision for Basal Cell Carcinoma of the Face.

OBJECTIVE: To assess the cost-effectiveness of Mohs micrographic surgery (MMS) compared with the surgical excision for both primary and recurrent basal cell carcinoma (BCC). DESIGN: A cost-effectiveness study performed alongside a prospective randomized clinical trial in which MMS was compared with surgical excision. SETTING: The study was carried out from 1999 to 2002 at the dermatology outpatient clinic of the University Hospital Maastricht, Maastricht, The Netherlands. PARTICIPANTS: A total of 408 primary (374 patients) and 204 recurrent (191 patients) cases of facial BCC were included. MAIN OUTCOME MEASURES: The mean total treatment costs of MMS and surgical excision for both primary and recurrent BCC and the incremental cost-effectiveness ratio, calculated as the difference in costs between MMS and surgical excision divided by their difference in effectiveness. The resulting ratio is defined as the incremental costs of MMS compared with surgical excision to prevent 1 additional recurrence. RESULTS: Compared with surgical excision, the total treatment costs of MMS are significantly higher (cost difference: primary BCC, 254 euros; 95% confidence interval, 181-324 euros; recurrent BCC, 249 euros; 95% confidence interval, 175-323 euros). For primary BCC, the incremental cost-effectiveness ratio was 29,231 euros, while the ratio for recurrent BCC amounted to 8094 euros. The acceptability curves showed that for these ratios, the probability of MMS being more cost-effective than surgical excision never reached 50%. CONCLUSIONS: At present, it does not seem cost-effective to introduce MMS on a large scale for both primary and recurrent BCC. However, because a 5-year period is normally required to determine definite recurrence rates, it is possible that MMS may become a cost-effective treatment for recurrent BCC.

Aged↗

PubMed2006

The added value of a multidisciplinary approach in diagnosing dementia: a review.

BACKGROUND: The impact of dementia constitutes a major public health challenge to our society. A multidisciplinary approach to dementia is generally recommended. OBJECTIVE: The objective of this review is to give an overview of the reported empirical studies on the added value of a multidisciplinary approach to diagnosing dementia, i.e. whether differences can be found between diagnostic multidisciplinary approaches, and/or monodisciplinary ones with respect to the diagnostic outcomes, the impact of diagnostics and their effects on quality of life and costs. METHOD: Critical review of studies which involve a multidisciplinary assessment of dementia. Literature was systematically searched in a number of international databases (Medline, PsychInfo, Pubmed and EconLit). A first selection was based on screening titles by one author. Interrater reliability was determined by scoring all abstracts by two authors. The reliability of selecting full articles was based on scoring a random sample by two authors. Kappa values were calculated. The Kappa statistic (k) was also used as an indicator of the diagnostic agreement between single disciplines and multidisciplinary teams. RESULTS: Five studies were identified as relevant for the purpose of this review. The most important outcome was the level of diagnostic agreement between single disciplines and multidisciplinary teams (MTs). Overall, there was substantial agreement (kappa: 0.37-0.76) on the diagnosis dementia (syndrome), but not on the subtypes (aetiology) (AD: 0.26-0.60; VD: 0.35-0.52; depression: 0.30-0.46). Diagnoses also differed between the disciplines. CONCLUSIONS: Merely studies on diagnostic accuracy were found, all using different reference standards. Kappa values were chosen as outcome measure and every diagnosis was considered of equal value. Therefore, the added value could not definitively be demonstrated. However, the potential added value of a multidisciplinary approach to diagnosing dementia probably lies in the ability to differentiate among the subtypes of dementia and to detect comorbid psychiatric conditions such as depression. Disciplines within an MT complement each other in establishing a specific diagnosis, which is considered to be the added value of such a multidisciplinary team.

Aged↗

PubMed2005

In unselected patients, elective single embryo transfer prevents all multiples, but results in significantly lower pregnancy rates compared with double embryo transfer: a randomized controlled trial.

BACKGROUND: Elective single embryo transfer (eSET) in a selected group of patients (i.e. young patients with at least one good quality embryo) reduces the number of multiple pregnancies in an IVF programme. However, the reduced overall multiple pregnancy rate (PR) is still unacceptably high. Therefore, a randomized controlled trial (RCT) was conducted comparing eSET and double embryo transfer (DET) in an unselected group of patients (i.e. irrespective of the woman's age or embryo quality). METHODS: Consenting unselected patients were randomized between eSET (RCT-eSET) (n = 154) or DET (RCT-DET) (n = 154). Randomization was performed just prior to the first embryo transfer, provided that at least two 2PN zygotes were available. Non-participants received our standard transfer policy [SP-eSET in a selected group of patients (n = 100), otherwise SP-DET (n = 122)]. RESULTS: The ongoing PR after RCT-eSET was significantly lower as compared with RCT-DET (21.4 versus 40.3%) and the twin PR was reduced from 21.0% after RCT-DET to 0% after RCT-eSET. The ongoing PRs after SP-eSET and SP-DET did not differ significantly (33.0 versus 30.3%), with an overall twin PR of 12.9%. CONCLUSION: To avoid twin pregnancies resulting from an IVF treatment, eSET should be applied in all patients. The consequence would be a halving of the ongoing PR as compared with applying a DET policy in all patients. The transfer of one embryo in a selected group of good prognosis patients leads to a less drastic reduction in PR but maintains a twin PR of 12.9%.

Adult↗

PubMed2005

Cost analysis of procedures related to the management of renal artery stenosis from various perspectives.

To determine the costs associated with the diagnostic work-up and percutaneous revascularization of renal artery stenosis from various perspectives. A prospective multicenter comparative study was conducted between 1998 and 2001. A total of 402 hypertensive patients with suspected renal artery stenosis were included. Costs were assessed of computed tomography angiography (CTA), magnetic resonance angiography (MRA), digital subtraction angiography (DSA), and percutaneous revascularization. From the societal perspective, DSA was the most costly (euro 1,721) and CTA the least costly diagnostic technique (euro 424). CTA was the least costly imaging procedure irrespective of the perspective used. The societal costs associated with percutaneous renal artery revascularization ranged from euro 2,680 to euro 6,172. Overall the radiology department incurred the largest proportion of the total societal costs. For the management of renal artery stenosis, performing the analysis from different perspectives leads to the same conclusion concerning the least costly diagnostic imaging and revascularization procedure.

Adolescent↗

PubMedDate not supplied

Surgical excision vs Mohs' micrographic surgery for basal-cell carcinoma of the face: randomised controlled trial.

BACKGROUND: Rates of recurrence of facial basal-cell carcinoma are consistently lower after Mohs' micrographic surgery (MMS) than after other treatments, such as surgical excision (SE). However, MMS is more time-consuming and therefore more expensive than SE. We investigated the types of facial basal-cell carcinomas in which MMS was more effective than SE. METHODS: 408 primary and 204 recurrent facial carcinomas (374 and 191 patients, respectively) were analysed separately in this prospective randomised study. Patients were assigned SE or MMS (each 204 primary, 102 recurrent), and received treatment at two hospitals in the Netherlands. The primary outcome was recurrence of carcinoma. Analysis was by intention to treat. FINDINGS: Of the basal-cell carcinomas included in the trial, 397 primary (198 MMS, 199 SE) and 201 recurrent (99, 102) tumours were actually treated. Of patients with primary carcinomas, 21 had both MMS and SE on different tumours. Nine with recurrent carcinomas had both treatments on different skin tumours. 66 primary and 13 recurrent carcinomas were lost to follow-up. Of the primary carcinomas, five (3%) recurred after SE compared with three (2%) after MMS during 30 months of follow-up. Of the recurrent carcinomas, three (3%) recurred after SE and none after MMS during 18 months of follow-up. Four recurrent carcinomas randomly assigned to the SE group were treated with MMS. Although both differences favoured MMS, they were not significant (primary, difference 1% [95% CI -2.5% to 3.7%], p=0.724; recurrent, 3.2% [-2.0% to 5.0%], p=0.119). Total operative costs of MMS were higher than those of SE (primary 405.79 Euros vs 216.86 Euros, recurrent 489.06 Euros vs 323.49 Euros; both p<0.001). INTERPRETATION: No definitive conclusion on recurrence rates of primary or recurrent basal-cell carcinomas is yet possible. Although recurrence rates were lower after MMS than after SE, the differences were not significant.

Aged↗