Cancer
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The Henry Ford Health System is a large, vertically integrated health care delivery system, with its core service delivery team comprised of a 1000-person salaried medical group. Oncology services are coordinated through its Cancer Center, which organizes regional distribution of oncology services for residents of southeast Michigan. ⋯ The System owns the largest health maintenance organization in Michigan (Health Alliance Plan) and its organizational structure affords the opportunity of offering purchasers specific oncology service contracting opportunities. Advantages of providing comprehensive oncology services through an integrated health system include: 1) standardized cancer care guidelines, 2) medical information exchange through an electronic medical record, 3) interdisciplinary cancer care provided by salaried physicians, minimizing potentially conflicting financial issues in treatment decisions, 4) state-of-the-art care afforded through availability of involvement in a large number of National Institutes of Health-sponsored clinical trials, 5) high standards of credentialing for oncology physicians, and 6) integrative managed care perspectives and continuous attention to cost and quality of care issues.
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Changing patterns of patient referral, decreasing payments for service provision, confusing network participation and reimbursement, as well as challenges to autonomous clinical decision-making jeopardize the traditional role of the oncologist in delivering cancer care. The cancer patient also may be at risk with unproven cancer delivery systems that displace the oncologist as decision-maker and care provider. The authors have constructed a model that preserves the oncologist's clinical and financial autonomy while meeting marketplace demands for improved access, decreasing costs and preserved quality of care. ⋯ The model created a low cost, high value provider not burdened by allocated overhead. Decentralized care enhanced community access, which improved patient compliance, enhanced patient satisfaction, decreased hospitalization, and thereby decreased cost. The horizontal structure permited the flexibility for varied purchaser products and politically sensitive physician and hospital provider panels. Consensus-based protocol and pathway determination achieved maximum physician participation, which preserved clinical and financial autonomy, decreased variance, and facilitated clinical research.
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Stereotactic brain biopsy is considered by many physicians to have significant morbidity and mortality rates with a high risk of sampling error resulting in misdiagnosis. The technical aspects necessary to perform the procedure safely and effectively are unfamiliar to most physicians. ⋯ Stereotactic brain biopsy is an extremely safe and effective procedure for evaluating intracranial lesions. Complex surgical planning can decrease the risk of potential complications and the use of intraoperative pathologic examination can improve the diagnostic yield for this procedure.
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Tamoxifen commonly is used as adjuvant therapy for all stages of breast carcinoma. However, several studies have suggested an association between the use of tamoxifen in breast carcinoma patients and the subsequent development of endometrial carcinoma. The objective of this study was to determine the relation between long term tamoxifen usage and the risk of endometrial carcinoma in patients with breast carcinoma and to determine whether the increase in the cumulative incidence of endometrial carcinoma observed in previous studies is a true increase. ⋯ The results of this study show that tamoxifen use does not appear to increase the incidence of subsequent endometrial carcinoma in patients with primary breast carcinoma who underwent annual screening for gynecologic carcinoma.
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Multicenter Study Clinical Trial
Interferon-alpha and chemohormonal therapy for patients with advanced melanoma: final results of a phase I-II study of the Cancer Biotherapy Research Group and the Mid-Atlantic Oncology Program.
The treatment of metastatic melanoma remains unsatisfactory despite encouraging results with biotherapy and combination chemotherapy. Combining these two modalities may improve outcomes for such patients. ⋯ The addition of interferon-alpha to this chemohormonal therapy regimen greatly increased toxicity without improving the response rate or survival for patients with metastatic melanoma.