Search

Background: Costs per consult are a vital consideration in determining the viability of a telemedicine practice. This study estimated total, average, and marginal cost curves for an ambulatory pediatric telemedicine practice.Objective: The objective of this study was to estimate the costs of providing 386 telemedicine clinical consults at school clinics during one school year (September, 1999 to May, 2000). Cost curves were used to estimate costs of clinics with varying numbers of consults.Research Design: This analysis used cost data from school clinics and a university medical center, which provided physician inputs. Standard cost-accounting procedures were used.Subjects: Cost analyses were conducted using 10 school clinics. Three hundred eighty-six consults were completed with 286 children. Seventy-one percent of the children were black or Hispanic.Results: The average costs of a telemedicine consult ranged from a high of $7328.17 when only one consult was done to a low of $173.13 when 129 consults were completed. At 165 consults, extrapolations from the cost curves suggested that the average costs of a telemedicine consult and a medical center pediatric ambulatory consult were approximately equal, a little more than $153. At 200 consults, telemedicine was estimated to be equal to or less costly than conventional ambulatory care visits by some 9.5%.Conclusions: Point and CI estimates of average costs suggest that telemedicine is cost competitive with conventional clinics when 200 or more consults are provided. The limited evidence available suggests that telemedicine consults also may be quality competitive. [ABSTRACT FROM AUTHOR]

Oncology services have been provided by telemedicine from the University of Kansas Medical Center (KUMC) for almost 10 years. We have analysed the costs associated with providing tele-oncology clinics to a rural Kansas town for two fiscal years, 1995 and 2000. The aim was to compare recent tele-oncology costs with those of the first year of tele-oncology practice. A study conducted in 1995 showed that the average cost was $812 per telemedicine consultation. Data from fiscal year 2000 showed that the average cost was $410 per telemedicine consultation, a decrease of almost 50%. As the tele-oncology practice in Kansas continues to grow, it can be expected that the costs associated with providing tele-oncology services will continue to decline. [ABSTRACT FROM AUTHOR]

Background: Clinical trial participation can improve overall survival and mitigate healthcare disparities for gynecologic cancer patients in low-volume community centers. This study aimed to assess the effectiveness of a centrally regulated but administratively decentralized electronic screening log system to identify eligible patients across a large catchment area for a National Cancer Institute (NCI)-designated cancer center's open clinical trials., Methods: Electronic screening log data collected between 2014 and 2021 from ten community partner sites in a single NCI-designated cancer center's catchment area were reviewed retrospectively. Clinical factors assessed included cancer site, primary versus recurrent disease status, and histology. Identification efficiency (the ratio of patients screened identified with an available trial) was calculated. Identification inefficiencies (failures to identify patients with a potentially relevant trial) were assessed, and etiologies were characterized., Results: Across ten community partner sites, 492 gynecologic cancer patients were screened for seven open clinical trials during the study period. This included 170 (34.5 %) ovarian cancer patients, 156 (31.7 %) endometrial cancer patients, and 119 (24.2 %) cervical cancer patients. Over 40 % had advanced stage disease, and 10.6 % had recurrent disease. Only three patients were identified as having a relevant open trial; none ultimately enrolled due to not meeting trial eligibility criteria. An additional 2-52 patients were retrospectively found to have a relevant trial available despite not being identified as such within the electronic screening log system. Up to 14.4 % of patients had one or more missing minimum data elements that hindered full evaluation of clinical trial availability. Re-screening patients when new trials open may identify 12-15 additional patients per recurrent disease trial., Conclusions: An electronic screening log system can increase awareness of gynecologic oncology clinical trials at a NCI-designated cancer center's community partner sites. However, it is inadequate as a single intervention to increase clinical trial enrollment. Providing adequate support staff, documenting clinical factors consistently, re-screening patients at relevant intervals, and coordinating with central study personnel may increase its utility., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Background: Whether pembrolizumab given both before surgery (neoadjuvant therapy) and after surgery (adjuvant therapy), as compared with pembrolizumab given as adjuvant therapy alone, would increase event-free survival among patients with resectable stage III or IV melanoma is unknown., Methods: In a phase 2 trial, we randomly assigned patients with clinically detectable, measurable stage IIIB to IVC melanoma that was amenable to surgical resection to three doses of neoadjuvant pembrolizumab, surgery, and 15 doses of adjuvant pembrolizumab (neoadjuvant-adjuvant group) or to surgery followed by pembrolizumab (200 mg intravenously every 3 weeks for a total of 18 doses) for approximately 1 year or until disease recurred or unacceptable toxic effects developed (adjuvant-only group). The primary end point was event-free survival in the intention-to-treat population. Events were defined as disease progression or toxic effects that precluded surgery; the inability to resect all gross disease; disease progression, surgical complications, or toxic effects of treatment that precluded the initiation of adjuvant therapy within 84 days after surgery; recurrence of melanoma after surgery; or death from any cause. Safety was also evaluated., Results: At a median follow-up of 14.7 months, the neoadjuvant-adjuvant group (154 patients) had significantly longer event-free survival than the adjuvant-only group (159 patients) (P = 0.004 by the log-rank test). In a landmark analysis, event-free survival at 2 years was 72% (95% confidence interval [CI], 64 to 80) in the neoadjuvant-adjuvant group and 49% (95% CI, 41 to 59) in the adjuvant-only group. The percentage of patients with treatment-related adverse events of grades 3 or higher during therapy was 12% in the neoadjuvant-adjuvant group and 14% in the adjuvant-only group., Conclusions: Among patients with resectable stage III or IV melanoma, event-free survival was significantly longer among those who received pembrolizumab both before and after surgery than among those who received adjuvant pembrolizumab alone. No new toxic effects were identified. (Funded by the National Cancer Institute and Merck Sharp and Dohme; S1801 ClinicalTrials.gov number, NCT03698019.)., (Copyright © 2023 Massachusetts Medical Society.)

Importance: The durability of the antibody response to COVID-19 vaccines in patients with cancer undergoing treatment or who received a stem cell transplant is unknown and may be associated with infection outcomes., Objective: To evaluate anti-SARS-CoV-2 spike protein receptor binding domain (anti-RBD) and neutralizing antibody (nAb) responses to COVID-19 vaccines longitudinally over 6 months in patients with cancer undergoing treatment or who received a stem cell transplant (SCT)., Design, Setting, and Participants: In this prospective, observational, longitudinal cross-sectional study of 453 patients with cancer undergoing treatment or who received an SCT at the University of Kansas Cancer Center in Kansas City, blood samples were obtained before 433 patients received a messenger RNA (mRNA) vaccine (BNT162b2 or mRNA-1273), after the first dose of the mRNA vaccine, and 1 month, 3 months, and 6 months after the second dose. Blood samples were also obtained 2, 4, and 7 months after 17 patients received the JNJ-78436735 vaccine. For patients receiving a third dose of an mRNA vaccine, blood samples were obtained 30 days after the third dose., Interventions: Blood samples and BNT162b2, mRNA-1273, or JNJ-78436735 vaccines., Main Outcomes and Measures: Geometric mean titers (GMTs) of the anti-RBD; the ratio of GMTs for analysis of demographic, disease, and treatment variables; the percentage of neutralization of anti-RBD antibodies; and the correlation between anti-RBD and nAb responses to the COVID-19 vaccines., Results: This study enrolled 453 patients (mean [SD] age, 60.4 [13,1] years; 253 [56%] were female). Of 450 patients, 273 (61%) received the BNT162b2 vaccine (Pfizer), 160 (36%) received the mRNA-1273 vaccine (Moderna), and 17 (4%) received the JNJ-7846735 vaccine (Johnson & Johnson). The GMTs of the anti-RBD for all patients were 1.70 (95% CI, 1.04-2.85) before vaccination, 18.65 (95% CI, 10.19-34.11) after the first dose, 470.38 (95% CI, 322.07-686.99) at 1 month after the second dose, 425.80 (95% CI, 322.24-562.64) at 3 months after the second dose, 447.23 (95% CI, 258.53-773.66) at 6 months after the second dose, and 9224.85 (95% CI, 2423.92-35107.55) after the third dose. The rate of threshold neutralization (≥30%) was observed in 203 of 252 patients (80%) 1 month after the second dose and in 135 of 166 patients (81%) 3 months after the second dose. Anti-RBD and nAb were highly correlated (Spearman correlation coefficient, 0.93 [0.92-0.94]; P < .001). Three months after the second dose, anti-RBD titers were lower in male vs female patients (ratio of GMTs, 0.52 [95% CI, 0.34-0.81]), patients older than 65 years vs patients 50 years or younger (ratio of GMTs, 0.38 [95% CI, 0.25-0.57]), and patients with hematologic malignant tumors vs solid tumors (ratio of GMTs, 0.40 [95% CI, 0.20-0.81])., Conclusions and Relevance: In this cross-sectional study, after 2 doses of an mRNA vaccine, anti-RBD titers peaked at 1 month and remained stable over the next 6 months. Patients older than 65 years of age, male patients, and patients with a hematologic malignant tumor had low antibody titers. Compared with the primary vaccine course, a 20-fold increase in titers from a third dose suggests a brisk B-cell anamnestic response in patients with cancer.

Background: Hospice care in rural areas is often characterized by provider shortages and vast geographical service areas to cover, making access to quality end-of-life care challenging. Telemedicine, broadly, is the utilization of interactive televideo (ITV) technology to provide health services over a distance. For over 25 years, telemedicine has been proposed as a solution to address access issues. In 2015, the University of Kansas Medical Center (Kansas City, Kansas) partnered with Hospice Services, Inc. (HSI) (Phillipsburg, Kansas), to augment traditional, face-to-face (FTF) hospice care with hospice care delivered through mobile tablets. Objective: This work examines the costs of TeleHospice (TH) (telemedicine use in hospice care) when compared with the costs of FTF hospice services. Design: Detailed administrative data from July 1, 2018, to December 31, 2018, were analyzed to estimate the costs of service after TH use was inculcated into routine practice. Results: his, which averages a daily census of 34 patients, conducted 257 calls, averaging 28 hours a month. The average time for a TH call was 18 and 17 minutes for nursing and medical director calls, respectively. Through various hospice functions, including administrative, patient, and nonpatient-related connections, HSI saved over $115,000 in staff travel time and mileage reimbursement. Administratively, by hosting their weekly 15-member interdisciplinary meeting through ITV, HSI saved $29,869 of staff travel time and mileage reimbursement. Conclusions: Our estimates indicate substantial cost saving potential with the use of TH services. Further research is needed to assess the effects of TH utilization on the experiences and subsequent cost of hospice care.

Background and objective The incidence of intracranial metastases from melanoma is on the rise. In this study, we aimed to determine the incidence of intracranial disease progression in patients on BRAF/MEK targeted therapy and immunotherapy in the setting of controlled or improving extracranial disease. Methods This was a single-center, retrospective review that involved patients who underwent stereotactic radiosurgery (SRS) for intracranial metastatic melanoma between January 1, 2014, and December 31, 2018. We focused on BRAF/MEK mutation status and dates of treatment with BRAF/MEK targeted therapy, immunotherapy [ipilimumab (Yervoy), nivolumab (Opdivo), or pembrolizumab (Keytruda)], and combination targeted and immunotherapy. Results A total of 51 patients were enrolled: 36 males and 15 females. The average age of the patients was 58.6 years, and 26 among them were BRAF mutation-positive. Seventeen had prior surgery with SRS as adjuvant therapy. The other 34 had SRS as primary treatment. Forty-two patients had extracranial disease present at the time of SRS. There were 34 patients treated with targeted and immune therapy. Overall, 16 patients (47.1%) demonstrated controlled or improving extracranial disease, and 18 (52.9%) demonstrated progressing extracranial disease at the time of SRS. In the subgroup analysis, patients treated with BRAF/MEK targeted therapy demonstrated a 75% rate of extracranial disease control. The extracranial disease was controlled in 43.75% of patients on immunotherapy with intracranial progression, while it was controlled in 30% of patients on both BRAF/MEK targeted therapy and immunotherapy with intracranial progression. Sixteen patients (47.1%) developed intracranial metastasis in our study while having a stable systemic disease with BRAF/MEK targeted therapy, immunotherapy, or a combination of the two. Conclusion Based on our findings, a systemic response to targeted therapy and immunotherapy does not necessarily parallel intracranial protection., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Gattozzi et al.)

Preclinical modeling suggests that intermittent BRAF inhibitor therapy may delay acquired resistance when blocking oncogenic BRAF V600 in melanoma 1,2 . We conducted S1320, a randomized, open-label, phase 2 clinical trial (NCT02196181) evaluating whether intermittent dosing of the BRAF inhibitor dabrafenib and the MEK inhibitor trametinib improves progression-free survival in patients with metastatic and unresectable BRAF V600 melanoma. Patients were enrolled at 68 academic and community sites nationally. All patients received continuous dabrafenib and trametinib during an 8-week lead-in period, after which patients with non-progressing tumors were randomized to either continuous or intermittent dosing of both drugs on a 3-week-off, 5-week-on schedule. The trial has completed accrual and 206 patients with similar baseline characteristics were randomized 1:1 to the two study arms (105 to continuous dosing, 101 to intermittent dosing). Continuous dosing yielded a statistically significant improvement in post-randomization progression-free survival compared with intermittent dosing (median 9.0 months versus 5.5 months, P = 0.064, pre-specified two-sided α = 0.2). Therefore, contrary to the initial hypothesis, intermittent dosing did not improve progression-free survival in patients. There were no differences in the secondary outcomes, including overall survival and the overall incidence of treatment-associated toxicity, between the two groups.

Background: In rural communities, providing hospice care can be a challenge. Hospice personnel sometimes travel great distances to reach patients, resulting in difficulty maintaining access, quality, cost-effectiveness, and safety. In 1998, the University of Kansas Medical Center piloted the country's first TeleHospice (TH) service. At that time, challenges with broad adoption due to cost and attitudes regarding technology were noted. A second TH project was launched in early 2017 using newer technology; this article updates that ongoing implementation., Methods: The Organizational Change Manager was followed for the guided selection of the hospice partner. The University of Kansas Medical Center partnered with Hospice Services, Inc. (HSI), a leader in rural hospice care, providing services to 16 Kansas counties. Along with mobile tablets, a secure cloud-based videoconferencing solution was chosen for ease of use., Results: From August 2017 through January 2018, 218 TH videoconferencing encounters including 917 attendees occurred. Calls were made for direct patient care, family support, and administrative purposes. These TH calls have been shown to save HSI money, and initial reports suggest they may strengthen the communication and relationships between staff, patients, and the patient's family., Conclusion: Finding innovative, cost-effective, and community-driven approaches such as TH are needed to continually advance hospice care. TeleHospice's potential to supplement and improve hospice services while reducing costs is significant, but continued research is needed to understand best fit within frontier hospices, to inform future urban applications, and to address reimbursement.

Purpose: Patients benefit from receiving cancer treatment closer to home when possible and at high-volume regional centers when specialized care is required. The purpose of this analysis was to estimate the economic impact of retaining more patients in-state for cancer clinical trials and care, which might offset some of the costs of establishing broader cancer trial and treatment networks., Method: Kansas Cancer Registry data were used to estimate the number of patients retained in-state for cancer care following the expansion of local cancer clinical trial options through the Midwest Cancer Alliance based at the University of Kansas Medical Center. The 2014 economic impact of this enhanced local clinical trial network was estimated in four parts: Medical spending was estimated on the basis of National Cancer Institute cost-of-care estimates. Household travel cost savings were estimated as the difference between in-state and out-of-state travel costs. Trial-related grant income was calculated from administrative records. Indirect and induced economic benefits to the state were estimated using an economic impact model., Results: The authors estimated that the enhanced local cancer clinical trial network resulted in approximately $6.9 million in additional economic activity in the state in 2014, or $362,000 per patient retained in-state. This estimate includes $3.6 million in direct spending and $3.3 million in indirect economic activity. The enhanced trial network also resulted in 45 additional jobs., Conclusions: Retaining patients in-state for cancer care and clinical trial participation allows patients to remain closer to home for care and enhances the state economy.

With a 5 year survival rate of approximately 80%, there is an increasing number of childhood cancer survivors in the United States. Childhood cancer survivors are at an increased risk for physical and psychosocial health problems many years after treatment. Long-term follow-up care should include education, development of individualized follow up plans and screening for health problems in accordance with the Children's Oncology Group survivor guidelines. Due to survivor, provider and healthcare system related barriers, adult survivors of childhood cancer (ASCC) infrequently are receiving care in accordance to these guidelines. In this paper we describe the stepwise process and collaboration between a children's hospital and an adult academic medical center that was implemented to develop the Survivorship Transition Clinic and address the needs of ASCC in our region. In the clinic model that we designed ASCC follow-up with a primary care physician in the adult setting who is knowledgeable about late effects of childhood cancer treatment and are provided transition support and education by a transition nurse navigator., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The teleoncology practice based at the University of Kansas Medical Center (KUMC) in Kansas City, Kansas, is one of the longest running practices of its kind worldwide. The practice began in 1995 and connected an oncologist at KUMC with a rural medical center in Hays, Kansas. Fifteen years later, the practice continues to thrive at Hays Medical Center and has also expanded to include two additional sites within the state-the Northeast Kansas Center for Health and Wellness in Horton and Goodland Regional Medical Center in Goodland-that offer regularly scheduled teleoncology clinics. While the KUMC practice has witnessed an expansion in service sites throughout its history, the practice has seen a significant decrease in the costs associated with providing such services since its inception. The cost decrease can, in part, be attributed to an increase in the number of teleoncology visits conducted through the practice since it began. In Fiscal Year 1995 (FY 1995), 103 teleoncology visits resulted in a cost per visit of $812. Five years later, the FY 2000 $410 per visit cost for 121 visits was almost half the cost identified in the initial cost analysis. The FY 2003 cost per visit for 219 visits saw another decrease to $401, and the most recent FY 2005 cost analysis yielded another decrease to $251 per visit for 235 visits. The data reported below are likely to be the best now available to track time trends in the cost of providing telemedicine or telehealth consultations. The Conclusion and Policy Recommendations at the end of this article will focus on both the cost-time profile and some other challenges and lessons learned.

Purpose: The purpose of this Phase II multi-institutional study was to define the efficacy and toxicity of ixabepilone in patients with advance pancreatic adenocarcinoma., Patients and Methods: Patients were required to have pancreatic adenocarcinoma and metastatic or recurrent disease that was not amenable to curative resection. Performance status was 0-1, and patients could not have had prior chemotherapy, or chemoradiation therapy for their advanced disease although prior local palliative radiation was allowed. Ixabepilone was administered iv as a 3 hour infusion every 21 days. Initially, the dose was 50 mg/m(2) but this was lowered to 40 mg/m(2) shortly after the trial opened because of concerns about neurotoxicity., Results: Sixty-two patients were registered however 2 were ineligible because they did not have recurrent or metastatic disease. For the 60 eligible patients, 22 had performance status of 0 and 38 performance status of 1. The estimated 6-month survival was 60% (95% CI 48%-72%) with a median survival of 7.2 months and an estimated time to treatment failure of 2.3 months. Out of 56 patients with measurable disease there were 5 confirmed partial responses for a confirmed response probability of 9% (95% CI 3%-20%) and 7 unconfirmed partial responses for an overall response probability of 21% (95% CI 12%-34%). Common toxicities were neutropenia/granulocytopenia, nausea and vomiting and neuropathy. There was one death, cause not determined but judged "possibly" related to treatment., Conclusion: Ixabepilone shows encouraging activity in patients with advanced pancreatic cancer and should be investigated further in this disease.

While telemedicine programme objectives, technologies and even philosophies will differ, certain common factors that enhance programme success can be identified. For example, a programme design which is driven by technological imperatives is likely to fail. It must also be recognized that telemedicine programmes cannot force remote sites to use their services. Thus developers must assess the needs for the proposed telemedicine service from a clinical, economic and technical perspective. From a clinical perspective, it is important to remember that certain clinical services can be provided via telemedicine while others cannot. Programme developers must recognize the significant role of the remote team in sustaining services; the on-site presenter is essential for the successful practice of telemedicine. Evaluating a telemedicine programme should be viewed as an integral step in its design and implementation. One site may define effectiveness in terms of access to services while another may measure success by cost savings. The success of future telemedicine programmes will be strongly related to their ability to recognize that they should be used to enhance current health-care delivery rather than to replace it.

There are advantages and disadvantages associated with utilization of online health services among individuals living with cancer. Accessing accurate, reliable health-related information online gives patients the power to enhance their understanding of information they obtain from their health care providers. However, online health information can often be confusing for patients to interpret, and it can sometimes be conflicting or incorrect. Based on a framework by Eysenbach, the following paper discusses various types of cancer services that are available online, and it addresses both positive and negative health outcomes that have been linked to utilizing such services.

Telehospice (TH) utilizes telemedicine technology to provide care at the end of life. A bistate project was launched in 1998 to study the use of home-based telemedicine for routine hospice care. Videophones were deployed for telenursing visits and evaluations by social workers. In order to determine what proportion of home hospice visits could be performed using currently available telemedicine technology, we reviewed clinical records retrospectively for hospice nurse home visits. Clinical notes documenting home nursing visits were obtained from two large hospices, one based in Kansas, and the other in Michigan. Records were randomly selected for patients who received hospice nurse visits during the month of January 2000. The charts were reviewed for patient demographic information, patient assessments, teaching activities, and interventions. Five hundred ninety-seven nursing notes were analyzed using an 85-item coding instrument. After careful review of the records, the coders also made a subjective observation regarding the suitability of each visit for telemedicine. As part of this analysis, we found that 64.5% of home hospice nursing visits could be performed by telemedicine. Using TH, it is possible to reduce the number of in-person visits, thereby significantly decreasing the cost of providing hospice care.

Twenty counties in Kansas were randomly selected from those designated as rural on the basis of their populations. A sample of 356 physicians and physicians' assistants in these counties was chosen. A postal survey was sent to the identified providers up to three times. One hundred and eighty-six of the questionnaires were returned (a response rate of 52%). In all, 76% of the respondents were physicians, 76% were men and 42% were family practitioners. Practitioners were classified as adopters or non-adopters of telemedicine, based on their report of whether they had ever referred one or more patients for a health-care consultation via telemedicine. Of the 167 participants who marked this item, 30 (18%) were adopters and 137 (82%) were non-adopters. Among the adopters, 16 (53%) said that they expected to use telemedicine with about the same frequency or more often in the future. In contrast, 61 (45%) non-adopters reported that they did not expect to refer patients by telemedicine in the future and 51 (37%) were unsure. Neither age (r = 0.16, P = 0.44) nor gender (chi2 = 2.35, P = 0.13) was related to the adoption variable or the number of referrals made to telemedicine clinics. The results suggest that adopters and non-adopters of telemedicine perceive its value very differently, and that an opportunity exists to promote the concept to non-adopters more effectively.

Malignant melanoma is rapidly increasing in the United States. Metastatic disease responds poorly to currently available chemotherapy. Pyrazine diazohydroxide (PZDH) is a new agent inhibiting DNA synthesis that is active in mouse tumor models and human xenografts and lacks cross resistance with multiple standard agents. In this phase II trial, patients with no prior chemotherapy or immunotherapy for metastatic disease and performance status (SWOG) of 0-1, were treated with pyrazine diazohydroxide at a dose of 100 mg/m2/day by i.v. bolus injection over 5-15 minutes for 5 consecutive days every 6 weeks. There were 23 eligible patients entered on this trial with 74% having PS of 0 and 91% having visceral metastases. There were no confirmed anti-tumor responses. The overall response rate is 0% (95% CI 0%-15%). Median overall survival is six months (95% CI 5-8 months). The most common toxicities were hematologic and consisted of lymphopenia, thrombocytopenia, anemia, and leukopenia. Fatigue. and nausea and vomiting were the next most common toxicities. Pyrazine diazohydroxide by this dose and schedule has insufficient activity in the treatment of disseminated malignant melanoma to warrant further investigation.

Since 1998, over 1300 telemedicine consultations have been provided to 12 schools in Kansas City. Despite the success of the programme, effective utilization of services has not occurred at all sites. We used a focus group and survey methods to investigate barriers to and catalysts for service adoption. The results showed that the school nurses strongly supported the programme. They valued its ability to provide health-care for the children and they welcomed their enhanced role. However, technical complexities and difficulties in obtaining parental consent were found to impede adoption. The nurses also expressed frustration with school personnel who had a poor understanding of their role in general as well as that of the telemedicine service. A new state reimbursement policy may promote greater understanding and provide a financial incentive for schools to adopt the telemedicine service.

Two large hospice organizations in Kansas and Michigan began a telehospice project with the goal of improving care at the end of life using telemedicine. Hospice nurses provided services using video directly to the homes of hospice patients. The telemedicine equipment operated over ordinary telephone lines. Nursing services included symptom assessment and psychospiritual evaluations. Patients lived in both urban and rural settings. Studies were designed to evaluate utilization patterns, access to care, patient/carer acceptance, medical outcomes and cost. During the first year of the project, telehospice care was initiated at five rural sites (two in Michigan and three in Kansas) and three urban sites (two in Michigan and one in Kansas). There was greater telehospice activity in Michigan than in Kansas, with 118 and 44 patients served, respectively. The urban site in Kansas withdrew from the study after participating for only nine months. In an effort to understand the difference in utilization patterns and reasons for withdrawing from the project, in-depth interviews of key study participants, including hospice administrators, nurses and research personnel, were conducted. Human factors appear to be important in the adoption of novel telemedicine applications.

Based on our experience of telemedicine in Kansas, we have identified several key factors in the success of a telemedicine practice. Very early in any project, it is important to bring together all participants (especially the physicians who are expected to refer patients) to define the need, outline specific goals, analyse and test the technology, and develop a plan for the implementation. As with traditional health-care, many partners must come together, including primary-care practitioners willing to shoulder day-to-day responsibility for management of complex patients, nurses with special expertise and consultants willing to work with a remote team using telemedicine. These individuals must accept the challenges and appreciate the rewards of working in a different practice model, in which communication and interdependence are critical for success. The telemedicine consultant is only as good as the local health-care team. The technology itself is only a small part of the equation.

A telehospice service is one in which telemedicine is used to provide hospice care in the home. To date, there have been few studies addressing the cost of home-based telemedical care, and none that specifically addresses cost-effectiveness for telehospice recipients. We measured costs for traditional hospice care as well as those associated with launching and operating a telehospice service. The costs were tallied over two separate three-month periods. For the first study period, costs were measured for traditional hospice home visits. During the second, expenses were monitored for traditional (in-person) and telehospice visits. For traditional care, the cost per visit was $126 and $141, for the first and secod time periods, respectively. The average telehospice visit cost was $29.

We studied patients' perceptions of telemedicine (interactive video) as a means of delivering specialist oncology/haematology care. Semistructured telephone interviews were performed with 22 patients attending a tele-oncology/haematology clinic in Kansas. Interviews were audio-taped and thematic content analysis of the transcripts was done. The response rate was 96%. All participants expressed satisfaction with their tele-consultations. For 50% of respondents, satisfaction with the tele-oncology/haematology clinic was qualified by two factors: participants also saw the specialist in person on occasions and the clinic was perceived as providing mainly a 'monitoring' function. In addition, 9 of the 22 patients expressed concern about the role of the nurse as a proxy for the doctor in performing certain parts of the physical examination. Overall, participants valued improved access to specialist services but had clear views as to the limitations of such a service. As the use of telecommunications technology grows, patient perspectives merit greater attention.

To determine what percentage of traditional home health nursing visits could be done by telemedicine, we carried out a retrospective review of nursing charts (clinical records). Data of two types were recorded. The objective data, which were abstracted from the records, included demographic information, patient assessments, teaching activities and interventions. The subjective data were the opinions of four observers as to whether the visit could have been done using currently available telemedicine technology. Records were sampled randomly for patients who had received home nursing care from three home health agencies in rural and urban areas during the winter and summer of 1996. A 54-item coding instrument was applied to 906 different charted home nursing visits. For 412 (46%) of these, the on-site nursing could reasonably have been replaced by telenursing. Significant factors determining the possible use of telenursing included primary diagnosis, number of interventions and patient age. Among the 10 most common primary diagnoses, the most amenable to telenursing care were chronic airway obstruction and joint disorders; the least amenable were coagulation disorders and anaemia. Telenursing visits could substitute for a substantial fraction of on-site home nursing visits. This has important implications in terms of reducing the cost of home nursing care.

A pilot study of telenursing for terminally ill patients at home was launched as a collaborative effort between KUMC and the Kendallwood Hospice. The service used the public telephone network. Interactive video equipment was installed in the homes of three nurses who received after-hours calls and in the homes of six hospice patients living in either Kansas or Missouri. Data concerning the utilization patterns were gathered for two separate three-month periods. Patients and caregivers reported general satisfaction with the telehospice system. Both the nurses and social worker providers became comfortable about video-calls. Nurses conducted video-assessments to determine whether an 'in person' visit was necessary. This was particularly helpful for rural patients who were living a long way from the base station. In addition, Kendallwood serves an urban population and, in certain areas, night-time nursing visits raise safety concerns.

The costs of providing oncology services in three different ways were measured. Services were provided to a peripheral hospital by: conventional clinics, in which the oncologist worked at the hospital concerned; outreach clinics, in which an oncologist was flown in periodically from a central hospital; telemedicine clinics, in which the oncologist at the central hospital practised via a video-link. During a one-year study period, 2400 patients were seen in conventional clinics, 81 in outreach clinics and 103 in telemedicine clinics. At these workloads the average costs per patient were $149, $897 and $812, respectively. However, the average costs cannot be compared directly without further information about the shape of the unit cost curves.

Although there are increasing numbers of telemedicine programmes in the USA, few have offered teleoncology services, so that the role of telemedicine in the practice of clinical oncology has yet to be fully defined. Telemedicine has been used successfully for direct patient care in Kansas. It is also a method of providing supportive care for the cancer patient, including assessments of pain and nutrition. In addition, televised tumour conferences and nursing education courses can help smaller communities develop a level of expertise that allows patients to be treated locally. Telemedicine may well be used in future for access to national and international cancer experts, and for participation in new cancer treatment protocols through cooperative group trials. When practising oncology via telemedicine, there are unique problems, including issues regarding technology (interactive video and radiograph review) and practice (patient/oncologist preferences and doctor-patient communication). Very little has been published in the area of tele-oncology so far, and studies concerning its efficacy, cost-effectiveness and the best organizational structure are still in progress. However, telemedicine appears to be a useful technique in the practice of oncology.

Costs were monitored for three different types of oncology practice: a telemedicine clinic and a fly-in outreach clinic, both held in rural areas, and a traditional clinic held in a city hospital. Total expenses were calculated over the year May 1995 to April 1996. The average cost per telemedicine visit was $812. The average cost per outreach clinic visit was $897. Flying in oncology support for this practice was therefore about 10% more costly than telemedicine. While the outreach cost may have been inappropriately high due to a slow start-up phase, it was still less expensive during this period to be seen via telemedicine. For comparison, the average cost per traditional oncology clinic visit was $149. However, this figure does not take into account the costs of access to a city-based service by rural patients.

Paraneoplastic pemphigus (PNP) is an autoimmune disorder occurring in the setting of an underlying neoplasm in which patients have polymorphous skin and mucous membrane lesions. We describe a patient with non-Hodgkin's lymphoma who developed bullous, ulcerating lesions in an area being treated with radiation therapy. The diagnosis of PNP was confirmed by indirect immunofluorescence of the patient's serum on rat bladder. The disorder was refractory to therapy, and ultimately the patient expired.

Haematological complications frequently occur in patients treated with chemotherapeutic agents. The degree and duration of bone marrow suppression depends upon the type of agent used. In general, agents that are cell cycle phase-specific tend to cause early myelosuppression with rapid marrow recovery, as compared to the non-phase-specific agents. Host factors including patient age, nutritional status, marrow infiltration or damage, and hepatic and renal function also affect haemotoxicity. Chemotherapeutic agents suppress proliferating or potentially proliferating precursors of neutrophils, platelets and red blood cells to the same extent. With most drugs, neutropenia tends to be dose limiting and more severe than thrombocytopenia. Because of the longer life span of red blood cells, severe anaemia is rarely a problem. The management of myelosuppression is multifaceted, and consists of aggressive antibiotic therapy to treat or prevent the infections that occur with neutropenia, as well as red blood cell and platelet transfusion support to correct anaemia and prevent bleeding. The role of the haemopoietic growth factors including erythropoietin, colony-stimulating factors and the interleukins is currently being evaluated in clinical trials. Haemolytic uraemic syndrome, haemolytic anaemia and therapy-induced myelodysplasia and/or acute leukaemia are uncommon and potentially severe complications of chemotherapeutic agents.

Five consecutive patients with severe aplastic anemia were treated with antithymocyte globulin followed by cyclosporin A. All received antithymocyte globulin initially, and because of lack of response within a 4 week period, cyclosporin was administered subsequently. Hematologic improvement occurred within four months of initiation of cyclosporin. Four patients no longer require blood product support, while one remains transfusion-dependent. In two patients, thrombocytopenia developed when the cyclosporin was tapered but re-institution of the drug resulted in a prompt improvement of counts. These observations indicate that the sequential use of antithymocyte globulin and cyclosporin may be an effective therapeutic approach in the treatment of severe aplastic anemia.

A patient with rheumatoid arthritis presented with pancytopenia 3 weeks after initiation of low-dose methotrexate administered orally. She had minimal renal insufficiency and hypoalbuminemia prior to initiation of methotrexate therapy, and had received a nonsteroidal anti-inflammatory drug concurrently. Bone marrow recovery occurred within 3 weeks. Patients receiving low-dose methotrexate therapy for rheumatoid arthritis require early monitoring for bone marrow injury, especially those who have risk factors for possible methotrexate toxicity.

Lactic acidosis, a rare and usually fatal complication of malignancy, is defined as a clinical condition in which the pH is less than or equal to 7.35 and the serum lactate level greater than or equal to 5 mEq/L. We have described the clinical aspects of four cases of lactic acidosis associated with malignancy, and have reviewed all reported cases of lactic acidosis in malignancy meeting the criteria. Rapid recognition of the condition and prompt institution of chemotherapy led to reversal of lactic acidosis in three of our four patients, but long-term survival is related to the responsiveness of the underlying tumor.