Research Topics: Cancer Nursing Research

PROSTATE CANCER

Prostate Cancer Incidence, Diagnosis and Staging             Cancer of the prostate gland is a common cause of death, accounting for about 2 to 3 percent of all male deaths (Guyton & Hall, 2000). Adenocarcinoma of the prostate accounts for the majority of malignancies in men over age 65. The etiology is unknown. Sarcoma of the prostate is rarely found in children. Undifferentiated prostatic carcinoma and squamous cell carcinoma of the prostate probably represent variants of adult adenocarcinoma and are less responsive to the usual measures of control.             Prostate cancer is also the most common cancer among men in the United Kingdom and the second most common cause of cancer-related deaths. In 1999, 20,842 new cases of prostate cancer were registered in the UK, giving a crude incidence rate of 75 cases per 100,000 men. Overall, 1 in 6 new cases of male cancers were prostate cancer and 9,491 men died from the disease. Prostate cancer accounts for 1 in 8 of all male cancer deaths (PR Newswire, 2002).             The usual prostatic malignancy is glandular, not unlike the histologic configuration of normal prostate. Frequent mitoses, stromal invasion, and involvement of perineural lymphatics constitute the principal histologic criteria of diagnosis.             Prostatic carcinoma is generally slowly progressive and may cause no symptoms. Late in the course of the disease, symptoms of bladder outlet obstruction, hematuria, and pyuria may appear. Matastases to the pelvis and lumbar spine may cause bone pain.             Stony hard induration of the prostate raises the suspicion of prostatic malignancy and must be distinguished from granulomatous prostatitis, prostatic tuberculosis, prostatic calculi, and other more unusual prostatic diseases. The firm and nodularly irregular prostate is pathognomonic of prostatic carcinoma, later exhibiting extension of induration and fixation of the gland to the rectum and the lateral pelvic walls.             There is a blood test for a protein called PSA, which can help to detect prostate cancer - but it needs to be used along with other tests to make a definite diagnosis. Prostatic carcinoma must be suspected on the basis of rectal findings. A solitary firm prostatic nodule should be biopsied immediately, preferably by open surgery to permit radical prostatectomy if indicated.             The more extensive processes may be defined by needle biopsy, either transrectally or transperineally. An elevated serum acid phosphatase indicates a large local tumor or metastases. Prostatic carcinoma produces osteoblastic bony metastases, and their radiographic demonstration in the presence of a stony hard prostate is diagnostic of cancer. Aspiration of bone marrow and demonstration of prostatic cellular configuration in metastatic cells confirm a diagnosis of incurable disease.   Risk Factors Associated with Prostate Cancer   Many men are unaware they even have prostate cancer, it develops from cells within the prostate gland but it is usually very slow growing. However, in some cases, it may grow more quickly and spread to other parts of the body. Age is a risk factor – as it is rare to find prostate cancer in men under 50 (Daily Record, 2002). About 9 per cent of prostate cancer cases are diagnosed in men in their 50s, 30 per cent in men in their 60s and 40 per cent in men in their 70s. But having an elderly relative with prostate cancer is not uncommon and does not increase a person’s own risk.             Three risk factors for prostate cancer are associated with an increased likelihood of developing aggressive prostate cancer or dying of the disease. People with high levels of the acid-labile subunit (ALS) glycoprotein that regulates the bioavailability of the hormone insulin-like growth factor 1 (IGF-1) may have an increased risk for prostate cancer and its aggressive forms. Low plasma levels of vitamin D appear to significantly increase the risk of aggressive prostate cancer, especially in patients with a particular polymorphism of the vitamin D receptor (Evans, 2005). The major risks are increasing age, especially past 50, a family history of the cancer, having a high-fat refined ‘Westernised’ diet and being of African or African-Caribbean origin (The Daily Mail, 2006). Knowing more about the risks won’t stop a person from getting prostate cancer, but it will increase their chances of spotting it as early as possible and getting it successfully treated.   Treatment Options – with reference to available guidelines               Once cancer of the prostate gland does occur, the cancerous cells are usually stimulated to more rapid growth by testosterone and are inhibited by removal of both testes so that testosterone cannot be formed (Guyton & Hall, 2000). Also, prostatic cancer can be usually can be inhibited by administration of estrogens.             Early and localized prostatic carcinoma may be cured by radical perineal or retropubic prostatectomy. Extensive local disease or metastases may preclude surgical cure, in which case diagnostic confirmation should be followed by hormonal control, irradiation, or both. The treatment of choice is bilateral orchiectomy accompanied by estrogens.             Failure to respond to the hormone, or reactivation of disease, may be controlled with bilateral surgical adrenalectomy or “medical adrenalectomy.” Irradiation may provide prompt relief of pain from bony metastases refractory to other treatment and may be efficacious in control of local disease as well; long-term regression and possible cure of prostatic carcinoma have been observed in some cases treated by radiotherapy.             Even some patients who have prostatic cancer that has already metastasized to almost all bones of the body can be successfully treated for a few months to years bye removal of the testes, by estrogen therapy, or both; after this therapy the metastases usually diminish in size and the bones partially heal (Guyton & Hall, 2000). This treatment does not stop the cancer but does slow it and sometimes greatly diminishes the severe bone pain.   External Beam Radiotherapy Technique               Radiotherapy is the treatment of disease with radiation, especially by selective irradiation with x-rays or other ionizing radiation and by ingestion of radioisotopes. It is also called as radiation therapy. Long-term control of prostate cancer can be achieved in a relatively high-risk patient population using interstitial brachytherapy in combination with external beam radiation therapy (Hitt, 2003). External beam radiation has proven successful in the treatment of localized prostate cancer and is associated with a success rate comparable to surgery for patients with localized prostate cancer. The survival rate for patients with localized prostate cancer, stages A and B, treated with external beam radiation is similar to that for age-adjusted cohorts without prostate cancer (Newman, 1996). External radiation generally is delivered in a daily dose of 180 cGy to 200 cGy for a period of 6 to 7 weeks (total dose 6200 cGy to 7400 cGy). Potential complications include impotence, incontinence, cystitis, urethral strictures, prostatitis, diarrhea, edema of the lower extremities and bone marrow suppression. Patients also may become physically tired, and they should be instructed to get as much rest as possible during their course of treatment. It is not uncommon for erythema to develop and for the skin to become red or dry in the area of treatment. Affected skin should be exposed to the air as much as possible and patients should be instructed to avoid wearing tight clothing. Patients also must be instructed not to use creams or lotions on affected skin without their doctor’s approval (Newman, 1996).   Support Mechanisms Available to these Patients within the Radiotherapy Department               Acute radiation sickness usually follows therapeutic irradiation. It is characterized by nausea, vomiting, diarrhea, anorexia, headache, malaise, and tachycardia of varying severity. The discomfort subsides within a few hours or days. Nutrition management of the client with cancer focuses on maximizing intake of nutrients and fluids (Potter & Perry, 2004).             Psychological interventions are also available for prostate cancer patients who underwent radiotherapy. These are usually handled by nurses. Response to this intervention has been very positive from both nurses and patients, nurses feel that they are better equipped to help patients emotionally and patients feel better able to cope with what can be a very traumatic time (PR Newswire Europe, 2005).       REFERENCES Guyton, A. and Hall, J. (2000). Textbook of Medical Physiology 10th Edition. Harcourt Asia Pte Ltd. Hitt, E. (2003). Combination Therapy Provides Long-Term PCa Control: External Beam Radiation/Brachytherapy Results in 70% 10-Year Relapse-Free Survival, Urology Times. Newman, J. (1996). Epidemiology, Diagnosis and Treatment of Prostate Cancer, Radiologic Technology. No Author. (2002). A to Z of Health Part 1: Prostate Cancer: Age a Risk Factor, Daily Record (Glasgow, Scotland). No Author. (2006). The Unknown Risks of Prostate Cancer, The Daily Mail (London, England). No Author. (2002). UK and US Companies Link to Accelerate Prostate Cancer Research, PR Newswire. No Author. (2005). UK Cancer Patients Set to Benefit from New Psychological Support Treatment, PR Newswire Europe. Potter, P. and Perry, A. (2004). Fundamentals of Nursing. Mosby. Credit:ivythesis.typepad.com

PROSTATE CANCER

Prostate Cancer Incidence, Diagnosis and Staging Cancer of the prostate gland is a common cause of death, accounting for abou...

Disability after Breast Cancer Surgery, Nursing Approach

Disability after Breast Cancer Surgery, Nursing Approach   Based on this research, breast cancer is the second most common cancer in the world and the fifth most common cause of cancer death among women worldwide.  And, the most common type of breast cancer is mammary ductal carcinoma.  There are two types of mammary ductal carcinoma; first is the Infiltrating Ductal Carcinoma; it is invasive proliferation of malignant cancerous cells in the breast tissue.  The second one is the Ductal Carcinoma in Situ; it is non invasive cells that may be malignant and are confined to the lactiferous ducts. The ductal carcinoma in situ is considered a stage zero cancer.  In this regards, there are various screening tests for the detection of cancerous cells in the breasts such as MRI imaging, mammograms and biopsies.  All these medical procedures are very crucial in detecting different types of breast cancer.  However, it is important to take into account that there are instances that current medical diagnostic procedure falls short.  In the event that inflammatory breast cancer is being detected, a surgical biopsy must be done through breast skin sample; so as to the sample of the underlying breast tissue. PET scan is mostly preferred testing technique by oncologists for inflammatory breast cancer; for it enables to reveal more the disease.  Moreover, most patients with inflammatory breast cancer should undergo chemotherapy to minimize the spread of the cancerous cells and to resolve skin issues.  After chemotherapy, a mastectomy must be performed; since lumpectomy is not recommended by the physicians for treatment of inflammatory breast cancer together with additional chemotherapy treatments. Whenever, the surgical area has healed and chemotherapy has been completed, most oncologists initiate a course of radiation to kill any remaining cancer cells in the breast area and underarm area.  Normally, oncologists use a staging system in evaluating the extent of an individual’s breast cancer.  Subsequently, cancer stages are based upon the following criteria: size of the tumor, whether or not the cancer is invasive or non invasive, as well as whether or not the cancer spread beyond the breast, and whether or not the lymph nodes are involved. (http://www.disabilitysecrets.com/social-security-disability-breast-cancer.html) Accordingly, the incidence of arm edema is common after breast cancer surgery. And, arm pain on motion is the most common disability seen among patients. Arm morbidity has a strong impact on the disability and quality of life level of breast cancer patients.  When you say arm morbidity, it is one of the most serious complications of breast cancer surgery and treatment that affects tremendously to the daily life of the breast cancer survivor.   Through Sentinel Node Biopsy (SLNB) procedure, many breast cancer patients having a high risk of developing arm lymph edema.  And, due to this, the most common impairments that have been reported experiencing by majority of the breast cancer survivors are reduction of range of motion (ROM) of the shoulder, numbness of the axilla or lateral chest wall, reduction of grip strength, as well as the arm edema with a high level of functional impairment due to excessive pain.  Nevertheless, the importance of these undesirable conditions of the breast cancer patients has been emphasized by Coster et al who focused on the importance of health professionals’ understanding about the accurate information on the majority of the incidence of postoperative arm morbidity prior to breast cancer surgery procedure.  In addition to that, modern treatment intervention for breast cancer caused more women to become long-term survivors; but   it should be also taken into account the health related quality of life that the patients have before surgery.    (http://www.disabilitysecrets.com/social-security-disability-breast-cancer.html) Furthermore, this study revealed that sixty seven   breast cancer patients who underwent Modified Radical Mastectomy ((MRM) or Breast Conserving Surgery (BCS) were being studied by medical experts.  MRM includes simple mastectomy with the help of Auxiliary Lymph Node Dissection (ALND).  Hence, breast cancer patients after their surgery are being treated to rehabilitation specialist for therapy and regular follow up.  More than that, after bilateral mastectomy, the patients is also experiencing severe debilitating cardiopulmonary disease prior to the treatment of their arm edema, active infection on the affected side.  In the same way, the patients are also experiencing neurologic and rheumatologic illnesses that composed of range of motion for both function of two arms. Clinical review shows that patients’ shoulder joint ROM is being measured in abduction, flexion, external and internal rotation using a goniometer.  This is done as the patient stands straight up facing the wall.  Aside from this, patients’ handgrip strength is being measured using an air pressure infusion hand dynamometer. An average of 3 grip strength measurements was being recorded for each hand. Additionally, the unaffected side is used to control for the evaluation of arm edema, handgrip strength and shoulder function. (http://journals.lww.com/smajournalonline/Fulltext/2010/01000/Disability_and_Health_Related_Quality_of_Life.10.aspx) References: (http://www.disabilitysecrets.com/social-security-disability-breast-cancer.html) (http://journals.lww.com/smajournalonline/Fulltext/2010/01000/Disability_and_Health_Related_Quality_of_Life.10.aspx)   Credit:ivythesis.typepad.com

Disability after Breast Cancer Surgery, Nursing Approach

Disability after Breast Cancer Surgery, Nursing Approach Based on this research, breast cancer is the second most common cancer in th...

Stoma or Cool-Rectal Cancer

Introduction               Stoma or Cool-rectal Cancer   Several studies have indicated that colorectal cancer is a cancer type that is high in frequency among both the male and female population (1999  2003). According to Parker, et al (1997), colorectal cancer is the second highest cancer disease (lung cancer being the most prevalent case) and the leading cause of cancer-related disease in the United States wherein an estimated 131, 000 Americans were diagnosed with colorectal cancer and 55, 000 died of the disease.    A number of medical researches and studies have claimed that proper screening and treatment of colorectal cancer can alleviate and decrease the statistics pertaining to the suffering and deaths of the disease. Medical studies have found out that detecting and removing adenomatous polyps can prevent the development of colorectal Aden carcinoma while detecting and treating early-stage cancers can lower the cases of deaths for colorectal cancer (Newcomb, et al, 1992).et al (1997) recommended that by 50 years of age, most persons at average risk for colorectal cancer should begin regular screening for polyps and malignancies (http://www.aafp.org).   Colorectal cancer is a disease in the digestive evident in the parts of the large intestine such as the colon or the rectum. As such, tumors form in the lining of the large intestine which is also called the large bowel. Colorectal cancer is common both among the male and female population as development of the disease normally arises at the age of 50. Colorectal cancer can be metastasis in which cancer spreads from its original location in the colon to other parts of the body like the liver or lungs (National Institute of Health, 2005). Figure 1 below presents the four sections of the colon where cancer can start or in the rectum. The walls of the colon and that of the rectum are composed of several tissue layers where cancer starts. From the inner layer, the cancer can grow to some or all of the layers. As such, the degree or stage of colorectal cancer is popularly screened and investigated through the examination of these tissue layers (American Cancer Society, Inc., 2005).   According to Burke (2003) “colorectal cancer arises from a series of histopathology and molecular changes caused by complex interactions between genetic susceptibility and environmental factors”. In this regard, the molecular changes are identified as (a) the multiple, acquired genetic alterations within colonist ontogenesis that promote malignant transformations and (b) the tumor suppressor genes which cause loss in the inhibition of cellular proliferation. Researches on carcinogenesis discovered mutations in the genes that are responsible for the repair of mismatched DNA pairs. These mismatched-gene-repair inactivation cases are found to be common among 15% of sporadic colorectal cancers.   The patient, having undergone polyps colonoscopy before complaining the symptoms of his rectal cancer increased his chance of experiencing the results of his latest medical examination and operation. As stated, polyps or the benign growths in the inner wall of the colon and rectum that increase a person’s risk of developing colorectal cancer. Familial polypus’s causes hundreds of polyps to form in the colon and rectum which lead to colorectal cancer if not treated early (Baddish, 2003).   Although it was his colon that has been previously operated, the inseparability of colon and rectal cancer is very thin that most people are diagnosed with both, simultaneously or consequently. His rectal examination revealed no masses but a strongly haemoccult-positive stool indicated the seriousness of the patient’s condition as a rectal cancer symptom. It is also obvious in this case that cancer in the colon spreads and has the tendency to recur to a person who has been treated.               Aside from his medical history of polyps operation, his age also contributed as a factor that increased his risk of colorectal cancer as the disease is more likely to occur as people get older, usually individuals who are over the age of fifty (2003). Patient RM is 63 years old which included him in the category of people with high risk of colorectal cancer. The latest medical condition of the patient is indicative of his early cancer stage in the rectum. The abdominoperineal resection made in his body is the usual medical procedure when diagnosed with rectal cancer.    The physical and psychological impact of cancer to its patients have been an important issues in the field of medicine (National Cancer Policy Board:2006). However, it is only recently that survivorship is coming to be recognized as a distinct phase of the can trajectory. Findings from research studies that have tracked the health and well-being of patients after cancer treatment has ended  have identified risks that both survivors and their health care providers should recognize. Advances in knowledge of how to manage conditions that arise in the post-treatment period have led to the development of some guidelines for health care providers. The coping period gives many chances to progress the health and quality of life of cancer survivors.     Background of the Study             Qualitative Study The complex and often idiosyncratic nature of the methods and the narrative style of findings  from qualitative studies make using the traditional format for reporting quantitative work awkward at best (Roskos:2000). In quantitative studies, research designs, sampling strategies, and statistical analysis procedures have been standardized and codified in ways that make it possible to summarize these in very few words. Similarly, findings are reported using terms and numbers that are relatively brief and straightforward (at least to those inside the quantitative research community). Qualitative methods are frequently adapted to the settings under investigation, and questions often emerge or change as studies progress, making codified descriptions of data gathering and analysis procedures difficult. Further, since understanding the contexts of a study is essential to interpreting the findings of a qualitative report, collapsing these into a few words in a review can distort important meanings generated in the study. Finally, since qualitative findings are descriptive in nature, shorthand versions like those found in traditional reviews of research are likely to leave out  a great deal of the descriptive power. Quality of Life Research The principal criteria guiding the patients’ acceptance of treatment are most often the patients’ subjective feelings i.e. the quality of their lives (Glise:1993). As the surgery asks patients to trade present discomfort and risk for future gains, in gauging the achievements of surgical treatment it is important to try to measure the quality of functional result vouchsafed to the patient. Another reason is that “surgery is forever” and cannot be undone. Broadening the choice of endpoints beyond traditional, so-called “hard” variables, and including SOL in surgical studies has advantages for both surgeons and patients. Because the impairments of function that may occur after different operations vary considerably, an operation-specific assessment of SOL for each type of surgical procedure is essential. Until now most of the SOL studies have been performed by non-surgeons with psychometric support, but it is time for the surgeons to provide leadership in SOL studies. Performing these studies will allow the surgeons to bridge another divide, open doors to showing more sensitivity, leading to better communication with their patients. A free and frank discussion, about SOL gains, as a benefit of surgery, at the time of counseling will go a long way in ensuring that the patients’ perspectives get their rightful place in decision-making. So the answer to the question, SOL measurements: who benefits? is that everyone benefits, surgeons as well as patients.   Aims and Objectives of the Study             The aim of this is to be able to identify and examine the patient’s perspective on the psychological impact of a stoma or cool-rectal cancer: The subject can be basically generalized and can be conducted using qualitative research method. The aim of the proposed study is:   “to explore and describe the psychological impact of stoma in the perspective of the patients.”               The following are the objectives of the research:   ·        To have in depth knowledge about stoma or cool-rectal cancer. ·        To identify the psychological impact of stoma to its patients after the treatment. ·        To examine the different issues of the stoma patients after their treatment. ·        To know how the stoma patients cope with the psychological impact of stoma after their treatment.   Methodology             The methodology of the study is qualitative in nature. The complex and often idiosyncratic nature of the methods and the narrative style of findings  from qualitative studies make using the traditional format for reporting quantitative work awkward at best (Roskos:2000). In quantitative studies, research designs, sampling strategies, and statistical analysis procedures have been standardized and codified in ways that make it possible to summarize these in very few words. Similarly, findings are reported using terms and numbers that are relatively brief and straightforward (at least to those inside the quantitative research community). Qualitative methods are frequently adapted to the settings under investigation, and questions often emerge or change as studies progress, making codified descriptions of data gathering and analysis procedures difficult. Further, since understanding the contexts of a study is essential to interpreting the findings of a qualitative report, collapsing these into a few words in a review can distort important meanings generated in the study. Finally, since qualitative findings are descriptive in nature, shorthand versions like those found in traditional reviews of research are likely to leave out  a great deal of the descriptive power. In order to come up with the most suitable research approaches and strategies for this study, the research process “onion” is used.  This is because conducting a research is like peeling the back layers of an onion—in order to come to the central issue of how to collect the necessary data needed to answer the research questions and objectives, important layers should be first peeled away. With the said process, the researcher was able to create an outline on what measures are most appropriate to be applied in the study. Saunders et al (2003) said that while it is not unusual for a researcher to first think of his research undertaking by considering whether one should, for instance, administer a questionnaire or conduct interviews, thoughts on this question should belong to the centre of the research ‘onion’. That is, in order to come to the central issue of how to collect the data needed to answer one’s research questions, there are important layers of the onion that need to be peeled away: the first layer raises the question of the research philosophy to adopt, the second considers the subject of research approach that flows from the research philosophy, the third examines the research strategy most applicable, the fourth layer refers to the time horizon a researcher applies to his research, and the fifth layer is the data collection methods to be used. The researcher conceptualized the research approach to be applied in this study by Saunders et al (2003), in order to come up with the pertinent data needed to answer the research questions stated in the first chapter, as well as to arrive to the fulfillment of this research undertaking’s objectives.             Then again, the research philosophy that is reflected in this study is positivism. With this research philosophy, a researcher prefers to work with an observable social reality in order to come up with law-like generalizations similar to those produced by the physical and natural scientists (Remedy et al, 1998), and in this tradition, the researcher becomes an objective analyst, coolly making detached interpretations about those data that have been collected in an apparently value-free manner (Saunders et al, 2003). In addition, the emphasis is on a highly structured methodology to facilitate replication (Gill & Johnson, 1997) and on quantifiable observations that lend themselves to statistical analysis (Saunders et al, 2003). In here, the assumption is that the researcher is independent of and neither affects nor is affected by the subject of the research (Remedy et al, 1998; Saunders et al, 1998).             Meanwhile, the second layer shows that this study has undertaken a deductive approach. Accordingly, this approach has five sequential stages: deducing a hypothesis; expressing the hypothesis in operational terms; testing this operational hypothesis; examining the specific outcome of the inquiry to either confirm the theory or indicate the need for its modification; and finally, modifying the theory in the light of the findings (if necessary) (Robson, 1993, p. 19).             Further, the deductive approach has a number of important characteristics. First, this approach is a search to explain causal relationships between variables, which consequently leading to the development of a hypothesis. Second, it involves the collection of a quantitative data (although it can, as well, use qualitative data), and these data are important to test a hypothesis that has been previously developed. The third characteristic of a deductive approach is that it controls to allow the testing of hypothesis. However, one must remember that with this approach, it is important that the researcher is independent of what is being observed—that is, the researcher should be objective and not subjective—so that the principle of scientific strictness will be pursued, as this approach emphasizes scientific principles. (Saunders et al, 2003)             Also, it is important that concepts are operationalisation, which will enable facts to be measured quantitatively. Finally, the deductive approach is generalization (e.g., to be able to generalize about regularities in human social behaviour, one must be able to select a sufficient numerical size of samples). (Saunders et al, 2003)   Data Collection and Strategies In order to obtain the desired data, the researcher has chosen to use the primary research data, which is to collect firsthand the data to be used for the outcome of the research. In able to do this, the researcher must have a data collection instrument to be presented to the respondents. Thus, the researchers have chosen obtaining data through the questionnaire. The questionnaire is administered by writing questions on a page and distributing it to the respondents, expecting them to return the paper with their answers on it. This is easier than other methods of data-collection (e.g., interview, observation, etc.) as particular details may be hard to talk about during interviews and cannot be drawn out from observation.               The advantage of using the questionnaires method is that the respondents have time to think of their answers, thus allowing smaller rate of errors. Also, concerning delicate matters, the respondents may feel more at ease when answering questionnaires as they are not required to speak with someone else in order to give information. The disadvantage of the questionnaire method is when the respondents are unable to read or write; then the questionnaire will be rendered useless by the respondents as they may need interpreters for the questionnaires. Thus, in case such that unlikely event may happen, then the researcher will have no choice but to quickly switch to the interview method, wherein the researcher will be allowed to interact with the respondent and ask the questions based on the prepared questionnaire.               During the interview, the interviewer encouraged the interviewee to clarify vague statements or to further elaborate on brief comments. More importantly, the interviewer was objective and did not attempt, in any way, to influence the interviewer’s statements. In order to do this, the interviewer did not share his/her own beliefs and opinions. Also, the questions thrown at the interviewees had been phrased clearly, so that interviewees can understand them, and they were delivered in neutral tone of voice. The researcher also avoided long questions, or those that are really made up of two or more questions, because as Robson (2002) said, by asking long-questions, the tendency to obtain a response for each aspect a researcher wants to explore will be lost. The researcher also avoided too many theoretical concepts or jargons, as the researcher’s understanding of such terms may vary from that of the interviewees. Also, during the interview, the researcher was determined to establish trust by not being too assertive and by being attentive to the interviewees’ responses. Finally, the researcher made sure that the interview did not last too long and did not consume much of the respondents’ time, as this may instigate uncooperativeness from the respondents Data Analysis Data will be analyzed based on the descriptive statistics performed in data processing. What’s more, the content analysis of documentary materials in this study was qualitative because the interpretations and conclusions from the findings depend almost entirely on the output in processing the frequency counts of the perceptions of the respondents. So, the occurrences of the perception of the respondents were tallied one by one, upon the frequency of the occurrences depends the analysis and interpretation. To further enhance the perception of the respondents, they were also given time for an interview that is subjected to their respective insight to the topics. The interview results were then used to justify their answers.             As has been mentioned above, content analysis of the documentary materials of this study was systematic. Hence, it follows scientific methods of research. The steps follow: ·        Recognizing the Problem- ·        Forming hypothesis- ·         Doing the library research. ·        Designing the study. ·        Developing the instrument. ·        Collecting the data. ·        Analyzing the data. ·        Making conclusions ·        Making recommendations Access and Sampling The study will consist of 10 stoma patients from different hospitals within the area. Respondents will be chosen randomly through stratified-random sampling approach. The researcher, in choosing subjects or respondents for the topic at hand, is usually thought of to have the power over who the respondents of the study will be. Such a task would have been easier, except a researcher cannot simply choose out of whim; the subjects must be selected carefully with the intention of having subjects who each posses characteristics that, when put together, will represent a community. It is not only themselves, whom these subjects will represent, but the bigger whole or the whole population. The characteristics which the researcher has chosen them for will determine which part of the community they belong and what part of the community they are representing. Thus, the choosing of the subjects must be based on their characteristics.   Ethical Consideration                 Because the respondents of the study will be cancer patients, ethical considerations should be observed strictly. First, the researcher will make sure that the time and place of the survey will be convenient to the patients and will be approved by their assigned specialist. Confidentiality of the respondents’ identity will also be ensured, as well as their responses. The objectives of the study will also be read and explained to the respondents so as they will understand why it is being conducted. Conclusion             In conclusion, this proposal has identified the different issues on the psychological impact of stoma in the perspectives of the clients. The study will focus on the quality of lie, body image, sexuality and sexual concerns, psychological adjustment, coping and practical adjustment of the patients. Credit:ivythesis.typepad.com

Stoma or Cool-Rectal Cancer

Introduction Stoma or Cool-rectal Cancer Several studies have indicated that colorectal cancer is a cancer type that i...

Nasopharyngeal Carcinoma (Stage II): a patient case study

Nasopharyngeal Carcinoma (Stage II): a patient case study   This patient case study focuses on nasopharyngeal carcinoma (NPC). Specifically, it analyses the progress of becoming and being ill as well as the process of recovery.  It identifies and explains how the illness affects the psychosocial functioning of the patient. It similarly analyses how the patient’s own psychosocial characteristics (e.g. belief, personality, social relationship etc.) influence the process of illness and recovery.   Nasopharyngeal Cancer: a brief description The National Cancer Institute (NCI) of the U.S. National Institutes of Health defines nasopharyngeal carcinoma (NPC) as a “cancer that forms in tissues of the nasopharynx (upper part of the throat behind the nose).” It is believed that nearly all nasopharyngeal cancers are considered squamous cell carcinomas due to its identified origin in flat cells lining the upper part of the throat behind the nose or the nasopharynx. Wang and colleagues (2008) agree that the usual case of nasopharyngeal carcinoma (NPC) include the upper part of the throat behind the nose with a well-developed group of lymphatics and cervical lymphadenopathy. They also describe it as a common cancer among Asians, especially in southern China. There have been abundant collections and a number of documented examples presented in epidemiological studies supporting the hypothesis of a relationship between childhood diet and later cancer. The more consistent evidence relates to the relationship between salted fish consumption in various Chinese populations and the risk of nasopharyngeal cancer. This relationship, which is supported by animal experimental work, shows that early dietary effects on cancer can be highly specific and of appreciable magnitude. There are, unfortunately, no other similar examples.   Stage II nasopharyngeal cancer From the same reference as above, “Stage II is divided into stage IIA and stage IIB. In stage IIA, cancer has spread from the nasopharynx (the upper part of the throat behind the nose) to the oropharynx (the middle part of the throat that includes the soft palate, the base of the tongue, and the tonsils), and/or to the nasal cavity. In stage IIB, cancer is found in the nasopharynx and has spread to lymph nodes on one side of the neck, or has spread to the area surrounding the nasopharynx and may have spread to lymph nodes on one side of the neck.”   Discussion One of the strategies employed in addressing a number of psychological problems and illnesses is the use of different kinds of psychotherapy. Aside from pharmacology, many psychiatrists and psychologists practice different techniques in psychotherapy in order to lessen drug-dependence of clients suffering from mental disorders. One of the psychological therapies used is Cognitive Behavioral Therapy, which helps enhance the therapeutic relationship that exists between the psychologist or psychiatrist and the client. However, Beck argues that the therapeutic relationship that exists between the client and the doctor in Cognitive Behavioral Therapy may not be sufficient to achieve a health or wholesome outcomes. With this statement, this essay discusses the concepts underlying Cognitive Behavior Therapy, with the emphasis on therapeutic relationship. Such concepts would be the basis for justifying Beck’s statement.   Cognitive Behavior Therapy  (1995) defines Cognitive Behavior Therapy as a branch of applied psychology that seeks to change problematic behavior through a number of methods. Methods include modifying the environmental contingencies that surround the problem, weakening previous conditioned associations that have resulted in maladaptive emotional reactions, offering clients more effective models of problem-solving and interpersonal behavior, seeking to change ways in which stimuli are recognized and interpreted in the first place, and offering an objectively superior basis for the therapeutic, counseling or casework roles of the psychologist or psychiatrist (1995). Such methods or approaches are not restricted to any one theoretical technique, but involves diverse yet interrelated strategies for providing new learning experiences that engage procedures and analysis. In addition, cognitive behavior therapy is guided by a number of principles, which serve to guide the therapist in the treatment of the client. Primarily, cognitive mediation processes are involved in human learning, such that the human organism responds mainly to cognitive representations of its environment rather than to the environment per se. Second, thoughts, feelings, and behavior are causally interrelated, thus, alterations to one aspect of the system will have effects on the other features. Third, cognitive activities are important in understanding psychopathology and producing therapeutic change. Fourth, cognitive processes can be cast into testable formulations that are integrated with behavioral paradigms, thus, desirable to combine with behavioral procedures, such as modeling, role-plays, and contingency management. Lastly, the task of the cognitive-behavior therapist is to act as a diagnostician, educator, and consultant, who assesses maladaptive cognitive processes, and works with the client to design learning experiences that may remediate these dysfunctional cognitions and behavioral patterns ( 1993). In this regard, it can be perceived that the process of cognitive behavior therapy involves addressing the feelings, behaviors and thoughts of the client during the therapy process in order to change or alter the maladaptive behavior of the client. In the process, the relationship between the client and the therapist is being emphasized.   Therapeutic Relationship in Cognitive Behavior Therapy             The review of Beck and Freeman in 1990 of cognitive behavioral treatment emphasizes that cognitive behavior therapy is based on the collaboration of the therapist and the client, thus, both of the parties work together to establish their goals, assignments, and means for success ( 1999). In this regard, the therapeutic relationship between the client and the therapist is being established. It has been reported that therapeutic relationship is at the absolute heart of psychotherapy, and is the vehicle whereby therapeutic change occurs ( 1991). It is regarded as the journey of both parties, which involves the participation, passion, cooperation, trust, and concern from both. In addition, a good therapeutic relationship is crucial to the success of cognitive behavior therapy for the therapist to carefully nurture the therapy alliance and pay attention to any ruptures within the relationship ( 2002). Because the success of the therapy lies on the relationship that exists between the therapist and the client, a careful and relevant approach must be employed by the therapist in order to ensure the effective treatment of the client.             Therapeutic relationships can be achieved through different means. Primarily, the therapist can use the process of collaboration, which involves establishing an equal partnership with the client through bringing skills, knowledge, emotion, and techniques that would help the client in the process. Another way is through formulation, which is a unique map of presenting problems or situations to the client that would integrate information from assessments of the therapist. Third, the therapist can use a Socratic dialogue or guided discovery, which involves gently probing or questioning for people’s meanings to stimulate alternative ideas. It explores and reflects on styles of reasoning and thinking differently. Lastly, the therapist can assign homework to the client, to allow him or her to try things out in between therapy sessions, thus, putting into practice what the client has learned in the therapy sessions ( 2005). With such methods, the therapeutic relationship between the client and the therapist can be established and determined. However, the problem that can be encountered in this sense is the fact that the client may have apprehensions towards the therapist, thus, limiting his or her disclosure of information. In this regard, the statement of Beck, emphasizing that such therapeutic relationship may not be enough to obtain desired outcomes come into picture.   Justifications of the Statement             The therapeutic relationship established through such means may not be effective due to a number of reasons. Primarily, the therapeutic relationship would not be effective in achieving healthy outcomes without the trust of the client to the therapist. It has been reported that the cognitive behavior therapist works with schemas, which are the collections of people’s beliefs, experiences and rules of behavior about themselves, others and the world (1999). If the client has schematic beliefs of mistrusting other people, then the therapist would have a hard time encouraging the client to disclose information. In this regard, the genuineness of the therapist must be observed, which has to do with confidence, appearing relaxed and at with one’s self, thus, presenting the therapy in a way that it would not sound artificial to put up a barrier between the therapist and the client ( 1995). Another hindrance to the practice is the lack of sensitivity on the part of the therapist. If the therapist is not sensitive enough for the needs of the client, then the client would not be able to obtain the best treatment that would help him or her to improve and develop as an individual. In this regard, non-possessive warmth must be expressed by the therapist, which consists of getting across to clients feelings of respect, liking, caring, acceptance, and concern, and managing these in a non-threatening way (1995). It is not enough that probing and collaboration with the client must be done, but the client must be able to feel the care and concern of the therapist. Therapeutic relationship is also not enough if there is incompatibility between the client and the therapist. Incompatibility can be observed through the incompatibility of the approaches of the therapist, and incompatibility on the response of the client that hinders adequate and effective assessment. In this regard, it can be perceived that the relationship of the client and the therapist must be based on compatible approaches and strategies that would not only benefit the client, but provide learning and experience on the part of the therapist as well. Having a client-therapist relationship is not a mechanical and predictable relationship that provides help to the client because of sympathy. In this regard, empathy must be extended by the therapist, which involves letting the client know that the therapist has a grasp on his or her problems, showing the client that the therapist sees things on the client’s perspective, and letting the client feel and see that the mood and feelings of the therapist are in tune with him or her ( 1995). As such, the trust and confidence of the client can be obtained. In addition, the time allotted by the therapist also counts in cognitive behavior therapy. Therapeutic relationships must not only focused in providing cognitive activities and workshops to the client, but making the client feel that his or her problems matter to the therapist through providing ample time for listening to the client. However, psychotherapies, such as cognitive behavior therapy takes a lot of time and effort on both the client and the therapist, is a time-consuming process, and its full analysis may take several years ( 1988). In this regard, each therapy session between the client and the therapist must be grasped and taken advantage in order to yield the best possible result. However, the problem that can be encountered due to the slow and time-consuming process is that the client or the therapist may get tired, given the slow development of the client. In this case, psychotherapeutic activities must be done simultaneously to ensure the speedy improvement and treatment of the client. From this, it can be perceived that the therapeutic relationship between the client and the therapist that was established through probing, collaborating, and assigning homework must not be based only on by-the-book approaches. Such activities must be done with the empathy, genuineness, and sensitivity of the therapist to the needs of the client.    Important Consideration: Aged Care Assessment Aged patients vary in physical needs, psychosocial needs including family involvement, and pathophysiological disorders that influence the person’s nursing care. In this case, an aged stroke patient is described whereas rapid assessment and early intervention is a requirement (1999). In terms of physical needs, aged patients need more assistance. Diet, nutrition, and eating are given special attention since the patient not able to chew and swallow foods. Since the patient is not capable of normal locomotion, his ability to dress and groom himself is no longer possible. Thus, assistance is always needed. In the same manner, a satisfactory nursing care is based on the need to maintain the skin care, feeding, hydration, positioning, and monitoring vital signs such as temperature, pulse, and blood pressure of the patient. On the other hand, psychosocial needs include attention, care, understanding, and continuous support from other people. The patient may have the tendency of having sudden changes in emotion. Depression is prevalent as a cause of self-acceptance of the disability. This is the reason why family involvement matters a lot especially in the recovery and therapy of the patient. Pathophysiological disorders that influence the person’s nursing care may range from the kind of stroke that the patient had experienced. In general, the risk of another stroke occurrence is recognized. The death of brain tissue may elicit several conditions. The person who reaches the ageing stage of life biologically changes over time due to cellular senescence. Cellular senescence is the ageing of cells and characterized by the loss of its ability to divide. According to  (2004), “the aging process may derive from changes occurring in parallel in different tissues due to intrinsic cellular mechanisms or changes in one tissue may be predominant”. Cell and tissues are considered to be significant reasons on why people age as described with the presence of strong genetic components that ( 2004; 2000). In the programmed based theories of aging, it was indicated that aging is not a result of random or stochastic process but rather driven by genetically regulated processes ( 2004). This means that the aging of an individual is natural.   Nursing refers to the functions and duties carried out by persons who have had formal education and training in the art and science of nursing. To promote the restoration and maintenance of health in their clients, nurses become more particular in enhancing their knowledge through integration with health and biological sciences (1993). As an applied discipline, the vocation of nursing evolves within a dynamic body of knowledge. The quality of nursing practice is dependent on the knowledge of individual practitioners as well as their willingness to engage in professional relationships and behaviors. Nurses are required to have the skills and know-how to explore, confirm, and direct the progress of nursing practice. Five value concepts uphold professional development: the (1) knowledge base, which is the foundation knowledge base upon which clinical practice decisions are made, (2) continuing education which comprise of the continuing learning activities that are crafted to benefit the individual and the profession, (3) mentoring and networking which are the professional relationships that are instituted with the intent of supportive growth for the individual as well as the profession, (4) research which is the qualitative and/or quantitative investigation of the factors which affects the professional nursing practice, and lastly (5) career development which are purposeful, planned strategies that are designed to boost short and long term professional goals ( 1998). It has not been long since nurses have had specialized training especially on patient management; these specialized trainings include the situation in which they are more likely to find themselves, thus affecting how they will react to the situations presented before them. The differences of their actions mean very much to the patients, and thus they must learn how to distinguish the different factors and be able to help their patients in achieving the best method of improving their health and returning to their vigorous states. Credit:ivythesis.typepad.com

Nasopharyngeal Carcinoma (Stage II): a patient case study

Nasopharyngeal Carcinoma (Stage II): a patient case study This patient case study focuses on nasopharyngeal carcinoma (NPC). Specifica...

CONTINUITY OF CARE IN CANCER PATIENTS

Abstract             In today’s world, the military physicians continually deploy, leaving their patients’ without a primary provider and making it difficult for them to practice continuity of care.  This is especially true in the case of cancer treatment.             As the seriousness of the disease grows, the importance of continuity also increases.  Unfortunately, the  (2003) review, found cancer care in the United States fragmented and without coordination.  The results of this study have shown a moderate level of continuity for  (IACH) cancer population, specifically for the breast cancer patients.  While the hospital should be pleased with this finding, it still needs to improve its level of continuity. One approach to emphasizing continuity of care is to evaluate it periodically.  If continuity is important, then how it is measured is also significant.              The study begins by attempting to compare, analyze, and recommend the most stable model to measure continuity. The objectives for conducting this study are as follows: first, to determine if the delivery of care of (IACH) provides optimal continuity of care; second, to determine which variables influence continuity of care; and third, to determine which variables isolate those patients in the greatest need of continuity.              The findings of the study expect to demonstrate that the current process for continuity might be fragmented and inefficient because the hospital’s main priority is supporting the active duty population.  At times, this, and the fact that the hospital is short of physicians, influences the staff’s ability to see the other beneficiaries.                                TABLE OF CONTENTS INTRODUCTION…………………………………………………………………..……3             Conditions which prompted the study………………………………..………13             Statement of the management question.……………………………………14             Literature Review………………………………………………………………15             Purpose…………………………………………………………………………27             Hypothesis………………………………………………………………………27 METHODS AND PROCEDURES…………………………..……………………………28             Subjects and Events……..……………………………………………………28             Study Design…..……………………………………………………………….30             Data Analysis……..……………………………………………………………31             Results…….……………………………………………………………………33             Limitations………………………………………………………………………37                        Ethical Considerations…………………………………………………………37 DISCUSSION AND CONCLUSIONS…………..……………………………………39 LIST OF REFERENCES………………………………………………………………43 APPENDICES….………………………………………………………………………49             Appendix A……………………………………………………………………..49             Appendix B………………………………………………….………………….50             Appendix C……………………………………………………………………..51             Appendix D……………………………………………………………………..53             Table 1………………………………………………………………………….54             Table 2………………………………………………………………………….55             Table 3………………………………………………………………………….56             Table 4………………………………………………………………………….57             Table 5………………………………………………………………………….58             Table 6………………………………………………………………………….59   Introduction             For the year 2000, those who died of cancer represented 23% of all deaths in the United States (, 2001).  The top ten cancer types vary for men, women, and children, but the chances for developing cancer are high in all groups (, 2003).  In addition, as the population of older Americans increases, the number of people with a cancer diagnosis will double, increasing the demand for resources.  As this disease’s population growth continues, the strain on consumption (treatments for cancer, control medications) will continue to rise (, 2003).             The (2001) reported several barriers to quality care for cancer patients.  These barriers include adequate cancer training for providers, poor management of cancer-related symptoms and lack of timely referrals.  Additionally, untold numbers of patients did not receive appropriate medical care because their geographical location was not conducive to receiving treatment. (2001).              These conditions resulted in the loss of public confidence in the system.  The (NCPB) responded by doing a review of the effectiveness of cancer services.  They found an “ad hoc and fragmented cancer care system that did not ensure access to care, lacks coordination, and is inefficient in its use of resources” (, 2003).  This prompted (IACH) to investigate continuity of care for their cancer patients as a way of improving patient treatment.               Continuity of care, specifically for cancer patients, in military health care has been included in many efforts of improving treatment.  It is one of the benefits reaped from the establishment of an Internet Tumor Board, a telemedicine system that is web-based to allow medical specialists to coordinate the care of cancer patients in the Asia-Pacific area.  The group that established this system had trouble with their patients being sent from one location to another, referring patients to the center facility for major treatments then handing them back to the local hospitals for continued treatment. Using this, they were able to eliminate potential for discontinuity that came from the transfers, and even from the frequent transfers of the military doctors themselves. (2000) This, and other researches and projects brought through agencies such as the U.S. Army Breast Cancer Research Program have sought ways in which treatment and care can be improved.             This then is an important component in providing quality patient care.  Research in continuity of care suggests a strong correlation between higher continuity and improved patient satisfaction.  Better continuity is associated with fewer hospitalizations, improved compliance, and lower emergency room use (, 2001).  Unfortunately, recent statistics reveal cancer patients are not receiving the best care due to inconsistent continuity (i.e. receiving care from multiple physicians).             The first step in this task began with settling on a definition of continuity.  The (2001),Crossing the     article, aptly defined continuity in the context of quality health care as “good to the extent it increases likelihood of desired health outcomes and consistent with current professional knowledge while also providing patients with appropriate services in a technically competent manner, good communication, shared decision-making and cultural sensitivity” (p. 6).              (1980) defined continuity as: An uninterrupted succession of events or the existence of a mechanism to bridge parts to an event.  In medical terms, the successions of events are episodes of an illness, and continuity is the means to bring the episodes together to evaluate the illness.  (p. 123)             With these definitions, we see that the primary intent of continuity is to improve follow–up of patient’s problems and facilitate efficiency in diagnostic workup and management.  The information about the plan of care passes from one visit to the next (1980).  Continuity of care is dependent on provider consistency, or involvement with a limited number of consistently available providers aware of the patient’s medical history. Thus the components of continuity include: ·         Medical care consistent with current knowledge ·         Competency ·         Appropriate services ·         Mechanism that brings multiple episodes of treatment together to evaluate the illness ·         Good communication ·         Shared decision making ·         Cultural sensitivity             Using these components of continuity of care, the researcher will explore the scope of cancer services provided by IACH providers.  This will include a review of the standards of practice accreditations that ensure quality cancer care, such as putting emphasis on the reliability of test data results which gives research its merit.             Currently though, IACH has earned the American College of Surgeons (ACoS) Commission on Cancer (CoC) accreditation in the Hospital Associate Cancer Program category.  This means on site services are limited but are available by referral (See Appendix A).  According to (2003) this also means that IACH’s cancer patients will receive: ·         Quality of care close to home. ·         Comprehensive care offering a range of state of the art services and equipment. ·         Multi-specialty, team approach to coordinate the best cancer treatment options available. ·         Access to cancer related information, education, and support. ·         A cancer registry that collects data on cancer type, stage, and treatment results and offers lifelong patient follow-up. ·         Information about clinical trials and new treatment options. (p. 2)                          In order to maintain accreditation, IACH must undergo an on-site review every three years, where continuity can be measured alongside the listed factors. To examine continuity of care in a given patient population, tools such as the Modified Continuity Index (MMCI) and others can be used.                           Continuity of care is a necessary part of the health care process; it leaves a positive impression on patients, and increases satisfaction.  With increased satisfaction, beneficiaries will continue to use the facility for their entire health Care needs.  But as military health care moves to the Next Generation of TRICARE contract, a military facility unable to provide a modern standard of care or deliver a perceived quality of care, equal to that provided in the civilian community may experience a loss of enrolled members (, 2000).               Conditions Which Prompted the Study              IACH underwent a re-organization to the military’s health plan TRICARE in 1988.  This resulted in the closure of the Department of Medicine.  IACH no longer had the capability or the staff to see other than active duty soldiers and dependents within their catchment area (See Appendix B).  All retirees and their families felt the impact of these decisions in 1998. By the end of 2000, this affected the cancer patients, forcing many to find a physician in the private sector.  Unfortunately, some of these patients did not find another provider.  According to , (, March 15, 2004), the Tumor Registrar at IACH, “It is this group and even some of those with outside providers that show up multiple times in IACH’s emergency room (ER) when they are very sick.”  This leaves a group of beneficiaries without a central source of care.              In October 2004, TRICARE, the military health plan, will transition to the Next Generation of TRICARE contract although the basic benefit structure (TRICARE Prime, Extra, Standard, and Plus) will remain unchanged.  Some of the benefit plan responsibilities will transfer from the TRICARE contractor to the military treatment facility (MTF) Commander.  This change provides incentives for the MTF to adopt best practices, provide measurable performance in customer service, quality of care, and access to care (, 2003).              The MTF, funded on historical data, will also receive the revenue paid in the past to the contractor.  The MTF will then pay the contractor for the services Prime enrolled beneficiaries receive in the network.  This provides the MTF with the flexibility to determine whether to provide in-house or network services based on cost effectiveness and the need of beneficiaries in the area.             Currently, IACH provides health Care services to a population of over 32,968 with a budget of .6 million for the 2002 fiscal year.  IACH authorized staff comprises 266 military, 360 civilians, and multiple contract personnel. The shortage of providers described here is incremented by IACH’s support on the war on terrorism by the deployment of their medical staff.             IACH is consciously aware that the shortage of physicians, inability to see all enrolled beneficiaries, and the changes in the TRICARE contract affects continuity of care.  A review of the current researches conducted in this field has shown that there are few who focus on the topic of continuity in this context. Rather, like those that are included under the Department of Defense’s Congressionally Directed Medical Research Programs, most of them only list continuity under the benefit of primary care improvement, or a requirement of it.             This study will help IACH measure the continuity of care for their breast cancer patients under these considerations.  Additionally, it should help determine the details of the factors that impact continuity of medical care.   Statement of the Management Question             This study will attempt to answer the questions identified from the literature associated with continuity of care and then apply them to the cancer patients at IACH. In particular, the researcher seeks to reply to the following questions: Research Question 1:  Do IACH providers offer continuity of care to their breast cancer patients?  Research Question 2: To what extent do outpatient visits, readmissions, and ER visits predict MMCI scores? Research Question 3:  Are there any relationships between MMCI scores with age, gender, race, beneficiary status and length of disease?  Research Question 4:  Do the participants’ MMCI scores differ by stage and site of cancer?         Literature Review             To evaluate the study methods and measurement techniques which have been employed in the study of continuity of care, ‘s includes those that used age at diagnosis, gender, and length of the relationship and stage of cancer as variables that might influence continuity of care.  These were used to answer the question of the relationship between continuity and emergency room (ER) visits and those between cancer type/stage and frequency of visits. But all of these studies do not agree on the definition and role of continuity. (pp. 1-19) So from this we see that the study of continuity involves visiting patterns and concentration of providers             On the other hand, (1994) felt that “continuity of care is established when a patient’s physician is able to understand interrelationships” (p. 14).  In other words, the patient’s feelings, past medical history, signs, symptoms, treatments, and responses to the treatments all need to be included to define or understand continuity of care.             Unfortunately, delivery of care to cancer patients is usually complex and uncoordinated, resulting in patient handoffs that delay care and decrease the quality of care over the continuum.  In turn, these developments are associated with bad health outcomes or even death (, 1999).              Regarding this, (1975) proposed that “there are certain medical conditions that need a higher degree of continuity.  For example, a patient will require additional follow-up appointments when there is a chronic problem than an injury requiring sutures.  The age of the population may also be important, as older age groups tend to have more severe long-term health problems.  The high mobility of the American population may render the goal of continuity unattainable.” (p. 141)                The importance of continuity of care increases with the seriousness of the condition.  When a lack of continuity occurs, it is disruptive and stressful for the patient with chronic conditions.  Patients perceive they receive better care if they have continuity, creating a higher level of trust (, 2002).  When seen by their regular physician, patient satisfaction increases with physician performance (1996).  Positive patient-provider relationships have shown to affect certain health behaviors such as lowering emergency room visits and even hospitalizations (, 2001).  Long-standing physician-patient ties foster less expensive and less intensive medical care (, 1996).             Efforts to improve continuity may improve the quality and outcomes of care (, 2001).  (2003) found in their literature review that “greater continuity is associated with reductions in hospitalizations, improvement in follow-up, increase in patient satisfaction, promotion of compliance with recommended care, and a reduction in duplication of tests” (p.992).               (2004), in their literature search, also found evidence that “continuity of care is associated with a decreased likelihood of future hospitalizations and less ER use” (p. 36).              (1975) proposed that continuity is a must for patients with chronic problems.  (2002) suggested the importance of continuity increases with the seriousness of the condition.  Other studies demonstrate that continuity decreases duplication of tests, ER visits, hospitalizations, which decrease the cost of care.  This information substantiated the value to further investigate continuity of care.  It thus became important to discover how other continuity studies’ formulated their research design.  Unfortunately, there is not any continuity of care research from military facilities to use as a model.              The following three studies either helps define variables, narrow definitions; show categorizing within a variable or present design possibility for this research.             First, (1987) started by defining measures of continuity as: the relationship between a patient and his or her primary provider and the generation of a meaningful numerical value that is easily understood.  They collected data for 201 patients.  The patients included made 1,154 visits to physicians over a two-year period. Fifty-nine percent were female; the average age was 28 with a range 1 year to 80, sixty-five percent had an assigned provider and twenty-six percent of the patients had all encounters with the same physician.  The result section included a COC, MCI, and MMCI scores for each patient (Appendix C). The findings substantiate that the use of UPC calculated scores of more than twice those calculated for COC.  The COC is sensitive to number of physicians seen and the MCI is results that may mislead users (, 1987).              Second, a study by (2003) collected data on deceased cancer patients (8,702) with a confirmed pathological cancer report.  They limited their research to office visits for the last 180 days of the subjects’ life.  The MMCI measured continuity of care as an independent variable and ER visits (total count of ER visits during each patient’s survival time) as the dependent variable.              They used descriptive statistics, followed by negative binomial regression analysis with adjustments for varying survival times to assess the association between continuity and the total number of ER visits.  Then variables associated with ER use in the bivariate analysis at a 0.1 level of significance and associated with continuity were included in the multivariate regression, along with the demographic variables (e.g., sex by age, sex by cancer death).              Finally, their subsequent modeling employed manual backward elimination to develop the final model of total emergency room use and association of provider continuity of care.  The skewed distribution of their continuity scores forced them to categorize continuity as being low (scores < 0.5), medium (scores 0.5 to < 0.8), and high (scores 0.8 and greater).              The majority of their patients were 65 years of age or older (72%), female (45.1%), male (54.9%), the most common cancer was lung (26%) followed by breast (10.2%), prostrate (9.2 %), colorectal (8.5%) and all others (53.1%).  The continuity scores ranges included low (0.02-0.47, (8.1%)), moderate (0.50-0.79, (35.6%)) and high (0.80-1.00, (56.4 %)), (, 2003).             And the third under the group of studies we’ve been following is by (2000), and was concerned with the effect of continuity of care on ER use.  It is of importance because it compares UPC and MMCI scores but also provides examples of definitions for variables, narrows the definition of visits, categorizing within a variable when needed and uses ER visits as a dependent variable.              Their analysis was performed by using the MMCI index as their main continuity measure.  However, since the UPC index is commonly used, they ran an additional analysis in place of the MMCI.  They defined visits as office or clinic visits to a physician, nurse practitioner, or a physician assistant.  They excluded ER visits because it was their dependent variable.  Additionally, they excluded special procedures and visits to other providers such as chiropractors, optometrists, and psychologists.  They categorized each patient’s ER visits into three levels (no ED visit, 1 ED visit or multiple visits).  This categorization allowed them to measure the effect of a single ER visit to multiple visits in the same model.  They did not examine ER visits as a continuous variable because of the extreme bias and kurtosis of the data violated the assumptions for linear regression.              In their main analysis, they measured the association between MMCI and ED visits by using a polychromatous logistic regression, with a 3-level categorization (no ER visit, 1 ER visit or multiple visits) of ED visits as the dependent variable.  They used a categorical data model because the different levels of the predictors did not meet the assumption of proportionality of odds.  They first ran the model with only continuity as the predictor variable.  They then ran the model after controlling for the number of office visits during the study.              Their previous analysis showed the number of office visits to be a strong negative confounder of the association between continuity and hospital use (i.e., office visits are positively associated with the dependent variable but negatively associated to the independent variable, so this would result in an apparent negative association between the independent and dependent variables.  They then ran the model with continuity and all control variables forced into the model to determine the effect of continuity.              Finally, they ran the model using a stepwise technique, to determine the best predictor model.  For the stepwise technique, they included predictors associated with ED visits from the univariate analysis with a P < .25 or the variables considered clinically relevant.  Stepwise selection showed P < .05.  They then added variables back to the model if they changed the co-efficient of the other variables by more than 15%.  The final model showed good predictor accuracy (c=0.81).  (pp. 334-335)             The preceding sections of this literature review establishes that continuity of care results in better health outcomes, helps coordinate care, increases trust, and reduces hospitalizations. Provider and emergency room visits also decrease which in turn lowers health care costs.  This prompted the researcher of this study to evaluate the best measurement for continuity of care.             The (1987), “study considered three models used in the past to measure continuity of care.  They found each of these continuity indexes did not truly represent the relationship of total number of visits to the total number of providers” (p.167).  Building on strengths of each measurement, the authors developed a new model that truly represents the total number of patient visits to the total number of providers.                The author explored measure to determine which is best suited to use in this research. The first measure, usual provider of care (UPC), oversimplifies the relationship between patient and provider.  UPC is simply a ratio, determined by limiting the visits to highest number of visits to one provider divided by the total number of providers.  The UPC produces a measure that ranges from zero to one.  The zero represents all visits to different providers and one represents all visits to the one provider.             UPC = V/Pr                                     (1)   V = Total number of Visits Pr = Total number of Providers             For example, if a patient has eight visits, (four visits to one physician and four visits to four other providers), the calculated UPC is 0.8 (4/5).  The problem with the UPC concept is that it does not accurately account for the total number of visits.  (1980) and (2003) have substantiated in their research that the UPC does not emphasize the number of different doctors seen.                         The second measure they examined was continuity of care (COC).   [(Pr)2 + (Pr)2 + (Pr)2 + (Pr)2  + (Pr)2)-V]             (2)                       [V (V-1)]                        V = Total number of visits Pr = Numbers of visits to provider             This formula attempts to account for visits to individual physicians.  For example, if a patient has a total of eight visits, four visits to a specific physician and the remaining four, each to different providers, COC would be 0.214 while the UPC would be 0.8.  The COC also produces a measure that ranges from zero to one.  The zero represents all visits to different providers and one represents all visits to the one provider.             The UPC does not accurately account for total number of visits.  Additionally, it falls rapidly with a large number of providers.             The third measure is the modified continuity index (MCI), which tries to provide sensitivity to the total number of visits and providers (1984).  The formula for MCI is as follows:   MCI=1-(Pr of providers / [V of visits + 0.1])                       (3) V = Total number of visits Pr = Numbers of visits to provider             This measure also generates a continuity score of zero to one.  The zero represents all visits to different providers and one represents all visits to the one provider.  Again, using a patient with eight visits, four visits to the same provider and the  remaining four to four different providers; UPC=0.8, COC=0.214 and the MCI=0.38.  While the MCI is less sensitive and less misleading, it still does not truly reflect the relationship to the total number of providers to the total number of visits.              The shortcomings of previous measures for continuity prompted (1987) to develop a new more meaningful measure, the MMCI.  This measurement tool is derived from the modified continuity index.  The MMCI produces a measure that will also range from zero to one.  The zero represents all visits to different providers and one represents all visits to the one provider.              The formula is as follows:   MMCI = 1-(Pr / [V  0.1])                      (4)                  1-(1 /[V + 0.1]) V = Total number of visits Pr = Numbers of visits to providers                       Again, using a patient with eight visits, four visits to the same provider and the remaining four to four different providers; the UPC = 0.8, COC=0.214, MCI=0.38 and the MMCI of 0.44.  The MMCI measure is not overly sensitive to the large number of providers and allows intuitive interpretation of continuity regardless of number of providers.             Before deciding to use a measurement, it is important to check the instrument’s validity or the extent to which a test measures what it purports to measure.  If a patient has two visits to two different providers (See Appendix C, row 2), the resulting MMCI is 0.10.   If you compare the results of the other measures UPC=0.50, COC=0.00, MCI=0.05 to the MMCI, it becomes clear that the MMCI is less misleading.  It also accurately represents a small number of visits.  This also establishes the preciseness of the index, which is one of the components of reliability.             Appendix C (Row 4) also demonstrates the value and validity of the MMCI.  If a patient has a total of three visits, two visits to one provider and one to a different provider, the score of the MMCI=0.51, UPC=0.67, COC 0.33, and the MCI=0.35.  The MMCI comes the closest to truly representing the total number of visits to total number of providers.  The COC and MCI scores give the impression of very low continuity and the UPC is misleading.             Reviewing the previous sections, this study then used the MMCI.              On that note, this study will employ the Modified Continuity Index (MMCI) to examine continuity of care in this patient population.  The researcher feels that previous measurement tools did not accurately represent the connection between the number of providers seen and total number of visits. The MMCI is the most consistent true measure and the most predominant model currently found in the literature.  It accounts for the degrees of dispersion among different providers.  Continuity for this study is a MMCI .51 or greater.                              Purpose                                                        This study was conducted with the following three objectives in mind. First, it will determine if the delivery of care for cancer patients at IACH provides optimal continuity of care.             Second, to determine which variables influence the continuity of care.  And third, to determine which variables isolate those patients in the greatest need of continuity of care.              The findings will demonstrate that the current process for continuity of care may be fragmented and inefficient.  This is because IACH’s main priority is supporting the active duty population.  At times, this influences the staff’s ability to see other patients.  Also the hospital and the military are below strength in number of physicians.  Lastly, patients often opt to see the first available provider instead of waiting for their assigned physician.   Hypothesis H0: The current process for care of breast cancer patients at IACH provides continuity of care.  H1: The current process of care for breast cancer patients at IACH does not provide continuity care.     Methods and Procedures             The purpose of this section is to review the description of the participants in this archival study, present the measures and procedures used to collect the data, and discuss the proposed treatment of the data.   Subjects and Events             The majority of IACH’s beneficiary population resides within the,          zip codes.  The use of the     database limited the participants to this area.  For inclusion in the research, each subject was an IACH beneficiary at time of the initial cancer diagnosis.  Additionally, patients must have had at least four outpatient visits.  The consensus of research related to continuity of care, supports the inclusion of patients with four or more visits.             IACH cancer patients’ data came from     database, the Composite Health Care System (CHCS), (for services within IACH) and the Military Health Services Management and Analysis Reporting Tool (M2), (for services outside IACH).  This study selected only specific data related to patients with the diagnosis of cancer.  Appointments for tests (X-ray, MRI, CT, labs) or treatments (chemotherapy) were not included.              The data collection included: diagnosis, date of diagnosis, age at diagnosis, stage of disease at diagnosis, and current documented “evidence” or “no evidence” of disease.  The demographic information included: beneficiary status (), age at diagnosis (), gender (), and race ().  The Composite Health Care System and M2 provided hospitalizations (number of separate admissions), number of providers, visits to a physician and to the ER.  Each subject had a MMCI Index calculated.  The continuity measure indicates the degree of continuity from January 1995-February 2004.  The MMCI value is a measure ranging from zero to one.              For the purposes of this study, MMCI scores .51 and greater represented continuity.  Visits are defined as outpatient visits to a provider but do not include visits for testing (labs, diagnostics (x-ray, CT, MRI) or chemotherapy) nor does it include emergency room visits in the MMCI calculations.  A provider is defined as licensed medical doctor, nurse practitioner or a physician assistant.             The accuracy of the data collected is an important aspect of any study.  To ensure the data is consistent, accurate, and precise (reliability), the researcher and the tumor registrar, reviewed it for accuracy.    Study Design             The review of past studies helped formulate the design for this research.  This is a retrospective study.    Army Community Hospital’s Tumor Registrar granted permission to use the ACTUR database to glean information for this analysis.              The    database provided cancer patients’ length of years with the diagnosis (continuous), staging (See Appendix D for coding), age at diagnosis and follow-up testing, and “evidence” (recorded as 1= no evidence of cancer and 2 = evidence of cancer).  The CHCS database provided beneficiary status (20=active duty/retirees, 30=all dependents), outpatient and ER visits, total number of providers, and IACH hospitalizations for each subject.  The Military Health Services Management and Analysis Reporting Tool (M2) database provided any appointments to outside providers and hospitalizations to other facilities.  The data went into one file.  With this merger, the influences on continuity emerged.     Data Analysis                  analyzed the data.  The use of descriptive analyses (i.e., summary statistics) of the variables helped determine their characteristics, estimate the proportion of participants that have those characteristics, discovered the associations among the different variables and measured cause and effect among the variables (, 2001).  Cause is defined as the variables that cause effects or influence continuity.  Descriptive statistics will analyzeed all subjects while regression was limited to the breast cancer types group with 4415 or more subjects.  This was the only group with 15 or more subjects.  (1996) found, for a reliable regression equation, 15 participants per predictor are needed” (p. 72). Research question 1:  Does IACH providers offer continuity of care to their cancer patients?              Each subject had a MMCI score calculated.  The definition for continuity of care is a MMCI score of .51 or greater.  The visits used to calculate the MMCI included visits both within IACH and outside the hospital from January 1995 thru February 2004.  The visits were limited to a licensed medical doctor, nurse practitioner or physician assistant.  The visits did not include treatments, diagnostic testing or therapy.  Both provider and visit data were checked and rechecked for accuracy by the researcher and the tumor registrar.  To answer this research question, the frequencies of the MMCI scores .51 or greater determined continuity of care.    Research question 2: To what extent do outpatient visits, readmissions, and ER visits predict MMCI scores?              A multiple regression examined the extent to which the independent variables of outpatient visits, readmissions, and ER visits predicted the dependent MMCI scores. The assumptions of regression included (multicollinearity (Some or all variables are highly correlated), linearity (the collection of data can be described as a straight line), and homoscedasticity (data evenly dispersed both above and below the regression line), (2001).  (1966) explain, “it is common in a multiple regression analysis to have a high degree of correlation between two or more explanatory variables (independent) that it is impossible to measure accurately their individual effects on the explained (dependent) variable” (p. 66).   Research question 3:  Are there relationships between MMCI scores with age (continuous), race (1=white, 2=other), gender, beneficiary status (20=active duty or retired, 30=dependents) and length of disease (continuous)?              “Evidence” and “no evidence” (determined by yearly follow-up testing) of cancer established any changes in severity of the diagnosis.  Specifically, the use of      correlation coefficient (determines relationships between variables) and point-biserial correlations (dichotomous variables that represent a natural dichotomy such as evidence and no evidence) determined correlations for continuous and dichotomous variables, respectively.    Research question 4:  Do the participants’ MMCI scores differ by stage (See Appendix D: codes) of cancer?              The assumptions of ,     normality (the normal distribution of the mean and the standard deviations) and equality of variance (measures the dispersion of the values determined by taking the square root of the variance) assessed the difference on MMCI scores by stage (See Appendix D).  Stage seven (distant metastases) was treated the same as other categories of stages.  The total number of outpatient visits, used in calculating MMCI, helps control for disease severity.  The outpatient visits help interpret the statistical relationship between the MMCI score and stage.  Results from other studies, show the total number of outpatient visits, is associated with severity of disease, increase in ER use, and hospitalizations.  Groups that exceed 5% (6) of the population of this study (118) will be used in the calculations (, 2001).     Results             One hundred and eighteen patients, 41 (34.7%) males and 77 (65.3%) females, were initially included in this study.  Eighty-eight (74.6%) were identified as Caucasian and 30 (25.4%) as “other.”  Of these patients, 42 (35.6%) had active duty or retired status, while 76 (64.4%) had dependents to include children.  The mean MMCI score for this group .59, which by definition signifies some continuity (continuity is >.51).  Table 1 presents the minimum, maximum, mean and standard deviations by age, years of cancer, number of visits, number of providers, ER visits, hospital days (HD), Total Providers (TP), Total visits (TV), MMCI and evidence of cancer.  Table 2 presents the frequency and percent of staging.             Of the initial sample, 44 women with breast cancer were examined to observe relationships among variables.  Thirty-four (77.3%) were identified as white and 10 (22.7%) as “other.”  Table 3 presents the minimum, maximum, mean and standard deviations by age, years of cancer, number of visits, number of providers, ER visits, HD, TP, TV, MMCI and evidence of cancer.  Table 4 presents the frequency and percent of staging.  In terms of evidence of cancer, 2 (4.5%) did have evidence while  42 (95.5%) were still cancer free.  The mean MMCI score for the breast patients was.58.    Research questions             The first research question examined if IACH provided continuity of care to their breast cancer patients.  Continuity of care was defined as an MMCI score at .51 or above; Table 3 shows that the mean MMCI score for breast cancer patients was .58 (SD=.22).  Therefore, continuity of care was given to these patients.              The second research question examined to what extent outpatient visits (OPV), readmissions (RA), and ER visits (ERV) predicted MMCI scores in breast cancer patients.  In terms of assumptions, standard scores were calculated for MMCI scores, and assessed for outliers, where there were none.  Multicollinearity was assessed with the variance inflation factor statistic (VIF).  VIF scores above 10.0 are problematic, and the VIF’s for the predictors were all below 2.0.  Linearity and constant variance were assessed by plotting the residuals verses the predicted values, where these assumptions were met.              The three predictors (OPV, RA, ERV), accounted for 17.1% of the variance in MMCI scores, and the model was marginally significant, F (3, 40) = 2.75, p = .055.  Table 5 shows that visits were a significant predictor of MMCI scores.              The third research question examined the relationships between MMCI score with age, race (Caucasian =1, other=2), years with cancer, and years seen.  Table 6 shows the correlation coefficients, where race and years with cancer were statistically significant with negative correlations.  The negative relationship with race indicates that “other” races tended to have higher MMCI scores than Caucasians.  The negative relationship of MMCI and years with cancer indicates that as years of cancer increases, MMCI scores decrease.              The fourth research question examined if differences existed in MMCI scores by stage (0 vs. 1 vs. 2/3).  Stages 2 and 3 were collapsed because there were too few (only 2) stage 2 patients.  The assumptions of normality were met, and    ’s homogeneity of variance was non-significant.  The     was not statistically significant, F (2, 41) = .01, ns.  All three groups had similar MMCI scores: stage 0 (M=.57, SD=.15), stage 1 (M=.58, SD=.23), stage 2/3 (M=.59, SD=.23).    Limitations             First, this study is limited to cancer patients treated at IACH.  The results are only applicable to the cancer patients in this one small military facility.  The analysis only included those patients with four of more visits.  All persons with one visit would be classified as having a perfect MMCI score, which is not an accurate representation.              The small number of subjects in this study may not show associations that might be found in a larger study.  Additionally in some cases, the use of the categorical data optimized manageability but also sacrificed the details of that data.  On the other hand, this type of data forms solid scientific evidence.             After establishing facts with the categorical data with this study, subsequent studies, such as qualitative researches, can be done to describe and support the details of its findings.   Ethical Considerations             The ethical conduct of this study was extremely important to ensure that the benefits of conducting this research was not overshadowed inappropriate data collection or disclosures.  The identities of the cancer patients were kept confidential as in keeping with the guidelines stated within the Belmont Report which follows the principles of (1) the respect for persons, (2) beneficence, and (3) justice. (2000)             According to the report, participants in a research must be treated as autonomous agents with the capability of deciding and making choices for themselves. The researcher is then accountable for participants with diminished autonomy, such as those with physical or mental incapacities. The participants should not come to any form of harm under the study, and the researcher should extend considerations for good outcome from the study to include the benefits to the participants themselves, science, and humanity.             Any participant should have voluntary informed consent to be in the study, and should have been informed of all procedures, purposes, and risks inherent therein, as well as being able of legal capacity to understand the information entailed by the research.   Discussion             As previously stated, the military health care setting is one of the more difficult settings in which to practice continuity.  In today’s world, the military physician faces being deployed, leaving their patients’ without a primary provider.  One approach to emphasizing continuity of care is to periodically evaluate it.  If continuity is important, then how it is measured is also significant.  The literature review substantiated the strengths of the MMCI.  But this study additionally demonstrated the strength of the MMCI to the other measurements in use.             The mean MMCI score for this study average was .59 and .58 for the breast patients.  For comparison, the          study with terminally ill cancer patients found a mean MMCI score of 0.78.  This indicates that while this group has a moderate measure of continuity, there is room for improvement.              Not only is it important to measure continuity but to also discover the factors that impact it.  Once these are isolated then a plan can be in place to increase continuity.  The outpatient visits, readmissions and ER visits model for the breast cancer patients was only moderately significant.  But, the number of outpatient visits proved to be a significant predictor of the MMCI scores.  This is supported by the work of .                     While the ER visits and readmissions were not significantly predictive of MMCI in this research, other studies by found ER visits are a predictor of MMCI scores.  Studies by,      studies found the number of readmissions are also a predictor of MMCI scores.              Interestingly this study did find that races other than Caucasians had higher MMCI scores.  This result has not been reported in any of the other studies.              Research by        has found as the years of cancer increase, the MMCI scores decrease. The findings of this study further support this literature.             Studies by       suggested that patients with chronic diseases require a higher degree of continuity.  In this research, MMCI scores did not show a difference by stage.  This is similar to the         study where there was no significant association between continuity of care and stage of cancer at diagnosis.              The results of this study have shown a moderate level of continuity for IACH’s cancer population and specifically the breast cancer patients.  The literature review established the importance of continuity increases with the seriousness of the disease.  Unfortunately, the National Cancer Institute 2003 review, found cancer care fragmented and without coordination.     Army Community Hospital might be able to increase the level of continuity with additional health care providers.  However, this option is not likely to occur.  Priorities demand providers fulfill their main mission, which is to deploy with the soldiers, ensure the medical fitness of troops that mobilize and demobilize, and care for the injured soldiers returning from the war in Iraq.  An alternative is substituting case managers to follow the cancer patient population.  They coordinate care and follow up with patients.    (1998) wrote “case management is a primary means to provide continuity of care across multiple institutions and practitioners” (p. 151).  While not the best answer, it might maximize continuity.  Another option is to refer patients to the local referral facilities.  Unfortunately, they also have capacity limits.  According to Health Resources and Services Administration (2004), not only is the state of Kansas short of health care providers but also has difficulty in recruiting them.              We are not the only military health Care facility facing lack of continuity of care for enrolled beneficiaries.  Given the impact and the increasing number of cancer patients, the leadership within the United States Army Medical Command would find the results of this study useful.  The MMCI model provides a measure to determine continuity of care.  The moderate continuity findings, suggest a need to improve continuity of care.  This will not only help the patient, but also reduce health care costs.  Ultimately, the leadership, soldiers, family members, and retirees within the greater Fort Riley community will benefit from the results of this study.              This concept will help revise the management of continuity of care for all patients.  It would further increase IACH’s reputation as providing efficient, effective, and quality health Care, while decreasing costs with a decrease in hospitalizations and emergency room visits.                 References   Appendix A   (, 2000)   <p style="line-height: 200%; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; font-size: 12.0pt; font-family: Arial; color: windowtext; font-weight: bold; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt"> The star is the location of    Army Community Hospital.  The arrows designate referral facilities used by IACH.  This allows the beneficiary population to receive the full spectrum of medical care. <p style="line-height: 200%; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; font-size: 12.0pt; font-family: Arial; color: windowtext; font-weight: bold; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt">     <p align="center" style="text-align: center; line-height: 200%; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; font-size: 12.0pt; font-family: Arial; color: windowtext; font-weight: bold; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt"> Appendix B <p style="line-height: 200%; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; font-size: 12.0pt; font-family: Arial; color: windowtext; font-weight: bold; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt">   <p align="center" style="text-align: center; line-height: 200%; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; font-size: 12.0pt; font-family: Arial; color: windowtext; font-weight: bold; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt"> (2000) <p style="line-height: 200%; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; font-size: 12.0pt; font-family: Arial; color: windowtext; font-weight: bold; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt">   <p style="line-height: 200%; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; font-size: 12.0pt; font-family: Arial; color: windowtext; font-weight: bold; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt"> The star represents the location of    Army Community Hospital.  The majority of beneficiaries of the medical facility live within the oblong shape.           <p align="center" style="text-align: center; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; line-height: 200%; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt"> Appendix C <p align="center" style="text-align: center; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; line-height: 200%; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt">   <p align="center" style="text-align: center; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; line-height: 200%; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt"> Comparisons of Continuity Scores <p align="center" style="text-align: center; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; line-height: 200%; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt">   Components of Continuity Formulas and Score Comparison Pr <p align="center" style="text-align: center; line-height: 200%; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt"> V DV UPC COC MCI MMCI 1      2 2 1.00 1.00 0.52 1.00 2 2 1,1 0.50 0.00 0.05 0.10 1 3 3 1.00 1.00 0.68 1.00 2 3 2,1 0.67 0.33 0.35 0.51 3 3 1,1,1 0.33 0.00 0.03 0.04 1 4 4 1.00 1.00 0.76 1.00 2 4 3,1 0.75 0.50 0.51 0.67 2 4 2,2 0.50 0.33 0.51 0.67 3 4 2,1,1 0.50 0.17 0.27 0.36 4 4 1,1,1,1 0.25 0.00 0.02 0.03 1 5 5 1.00 1.00 0.80 1.00 2 5 4,1 0.80 0.60 0.61 0.76 2 5 3,2 0.60 0.40 0.61 0.76 3 5 3,1,1 0.60 0.30 0.41 0.51 3 5 2,2,1 0.40 0.20 0.41 0.51 4 5 2,1,1,1 0.60 0.10 0.22 0.28 5 5 1,1,1,1,1 0.20 0.00 0.02 0.03   Appendix D Staging and Code Numbers for Cancer Staging of Cancer   Table 1   Minimum, Maximum, Mean and Standard Deviations by Age, Years of Cancer, Number of Visits, Number of Providers, ER Visits, HD, TP, TV, MMCI And Evidence of Cancer    Variable Min Max M SD Age 7 87 52.58 15.08 Yrs cancer 1 34 7.99 6.41 Visits 4 176 23.04 21.66 Provider 1 65 9.52 8.86 Years seen 0 10 4.14 2.16 ER visits 0 230 3.87 21.24 Hospital 0 4 0.48 0.84 HD 1 30 5.68 6.60 TP 1 65       9.16   7.65 TV 4 176 22.97 21.27 MMCI 0 1 0.59 0.21 Evid Canc. 1 2        1.14 0.34                                                                                         Table 2 Frequency and Percent of Staging   Staging  Freq   Percent   0 15 12.7   1 59 50.0   2 10  8.5   3 18 15.3   4  4  3.4   5  1  0.8   6  0  0.0   7 11  9.3 Note. n=118. Table 3   Minimum, Maximum, Mean And Standard Deviations By Age, Number Of Visits, Number Of Providers, Years Of Cancer, Years Seen, ER Visits, Number Of Hospitalizations, Number Of Day In Hospital, and MMCI   Variable Min Max M SD Age 31 72     53.39 9.66 Visits 6 69     24.30   17.74 Provider 1 28 9.70 6.25 Years Cancer 1 24 9.07 6.24 Years seen 0 8 4.09 1.93 ER visits 0 13 2.16 3.21 Hospital 0 4 0.48 0.85 Days 0 10 1.41 2.81 MMCI 0.12 1 0.58 0.22                                                                     Table 4                         Frequency and Percent of Staging   Stage Freq Percent 0 5 11.4 1 27 61.4 2 2 4.5 3 10 22.7                     Note. n=44       Table 5 Regression: B, Standard Error, Beta Weights, t, and Significance Levels for Variables and MMCI scores as the Criterion   Variables B SE Beta t Sig. Out. Visits .004 .002 .361 2.431 .020 ER Visit -.019 .010 -.276 -1.861 .070 Hospital .014 .037 .053 .367 .716     Table 6   Correlation for MMCI scores with Age, Race, Years with Cancer, and Years Seen     MMCI Age .09 Race -.32* Years cancer -.40** Years seen -.03   Note.  n=44, race (Caucasian=1, other=2), *p < .05, **p < 01.      </div> Credit:ivythesis.typepad.com

CONTINUITY OF CARE IN CANCER PATIENTS

Abstract In today’s world, the military physicians continually deploy, leaving their patients’ without a primary provide...